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PubMed2001

Implementation of the Interdisciplinary Generalist Curriculum Project: considerations of structure, funding, and design.

Implementation of the Interdisciplinary Generalist Curriculum (IGC) Project involved complex processes that reflect structural, funding, and intervention design considerations. Among structural considerations, the IGC Project benefited from a national structure above the level of the demonstration schools. Governance by committee was highly effective because it harnessed and balanced power. At the national level, governance by committee was enhanced by strong central coordination, and it had a role-modeling effect for governance at the school level. The IGC experience over the seven-year course of the project suggests that it is important to revisit the role of a national advisory committee over time and to revise that role as warranted. Funding considerations, including the importance of funding evaluation for a period of time long enough to measure intended impacts and the length and amount of funding to demonstration schools, are discussed. Prescription of the IGC intervention and the focus on years one and two of medical education are critical design considerations. The authors conclude that the IGC Project used relatively few federal dollars to demonstrate a highly prescribed intervention in a limited number of medical schools toward a clear and limited goal. IGC lessons apply to programs specifically targeting primary care education, but also to other medical school curricular innovations, and perhaps, to a larger framework of multi-site educational interventions.

Curriculum↗
PubMed2001

How did we make the Interdisciplinary Generalist Curriculum Project work? National efforts to facilitate success.

The Interdisciplinary Generalist Curriculum (IGC) Project created curricular changes at the participating schools with very little direct financial support. A reconsideration of the process of this national effort reveals many intangible elements that were as critical to the project's successes as were the direct dollars. Those factors included careful attention to the criteria for school selection, specific project requirements that allowed institutional flexibility in project evolution, national assistance in program implementation, early and ongoing national recognition for project schools, and a highly organized, involved, and goal-oriented national organization. This national initiative provides a successful model for future funding of projects in this era of dwindling financial support for medical education innovation.

Curriculum↗
PubMed2001

How did we make the Interdisciplinary Generalist Curriculum Project work? School-level efforts to facilitate success.

This article examines how the schools funded by the Interdisciplinary Generalist Curriculum (IGC) Project handled the process of planning and implementing their proposals; incorporated the IGC requirements as templates for changes in educational programs and organizational infrastructures; and identified key educational and management issues that emerged over time. How collaboration flourished at each IGC school was the central functional ingredient for successful implementation. Shared power and support from the dean were essential for success. The need for excellent channels of communication among all constituencies in the process of curricular change cannot be overemphasized. The most common approach was the addition of the new interdisciplinary clinical curriculum to the existing, usually discipline-based, curriculum, with attempts to establish integrative horizontal connections among concurrent courses in years one and two. The integration, sequencing, and correlating of basic science and clinical material occupied much of the IGC course directors' time in the early stages. Several approaches were used to help ensure a beneficial initial clinical experience for medical students, while accepting that a uniform experience for all students was not attainable or necessary. Encouraging active learning on the part of students was a goal of IGC schools' planning in and of itself. The splash of establishing interdisciplinary communication structures and greater melding of disciplinary cultures that occurred at and among the IGC schools appeared to lead to ripple effects that were recognized within the first year of planning and early implementation.

Communication↗
PubMed2001

What did we learn about student and faculty "backlash" to the Interdisciplinary Generalist Curriculum Project?

There was student and faculty backlash against the Interdisciplinary Generalist Curriculum (IGC) Project innovations at all ten schools involved. Students may react strongly to requirements and experiences they find onerous, and often reacted to being "preached at" and being told what they should value and believe. Backlash was not limited to students. A complaint heard in virtually all schools was that the basic science faculty barely had enough time to adequately cover their topics as it was, and now they were being asked to give up time for clinical experiences and topics. Despite the backlash, the authors point out that the vast majority of students endorsed the value of the preceptorship experience and that reaction to the IGC Project did not necessarily translate into negative perceptions of primary care medicine. Each IGC Project school made strategic decisions in response to backlash. Among the various efforts undertaken were enhanced communication and clarification, persistence and "watchful waiting," programmatic changes, and elimination of program components that were not working. These various efforts appear to have paid off, as most schools reported that backlash diminished over time. Lessons learned about backlash against new curricular innovations were that (1) backlash, however defined, is inevitable; (2) communication, coordination, and cooperation are essential; (3) flexibility, compromise, and willingness to change are essential; and (4) "watchful waiting" can be an effective response to some forms of backlash.

Attitude↗
PubMed2001

The Interdisciplinary Generalist Curriculum Project at Joan C. Edwards School of Medicine at Marshall University.

The Interdisciplinary Generalist Curriculum (IGC) Project was designed to enhance interest in and support of generalism during the first two years of medical education. The original goals at Joan C. Edwards School of Medicine at Marshall University included the design and implementation of a core curriculum, Introduction to Patient Care (IPC), and enhancement of teaching excellence through faculty development. The core curriculum facilitated integration with the basic sciences and early introduction of physical examination skills, which were further developed in longitudinal clinical experiences with mentors. Although it was not originally intended to include basic scientists in the preceptor groups, they became important additions and created additional opportunities for interdisciplinary teaching and reciprocal learning. The mentor program, another well-received and intended curriculum change, evolved from a structured experience to a more flexible component of the curriculum. The program met the requirements of the IGC Project but 53% of the originally intended mentor time was achievable, due to curriculum constraints. Faculty development, another success, was originally intended to target IPC faculty but ultimately became a university-wide effort. The changes implemented as a result of the IGC Project continue to flourish beyond the funding period and have become integral aspects of the curriculum and the medical school.

Curriculum↗
PubMed2001

The Interdisciplinary Generalist Curriculum Project at Nova Southeastern University College of Osteopathic Medicine.

Nova Southeastern University College of Osteopathic Medicine (Nova Southeastern) proposed for its IGC Project to match students with community-based generalist physician role models through partnership with a managed care organization (MCO). An unanticipated corporate merger between the initial managed care partner and another health plan resulted in Nova Southeastern's negotiating training partnerships with multiple MCOS: Other program elements that differed from what was originally proposed include provision of an interactive utilization management session at a hospital or skilled nursing facility, rather than a headquarters-based utilization management rotation; combining multiple learning experiences for students within a single MCO session; having a portion of the training take place at field-based sites outside MCO headquarters or after normal business hours (i.e., MCO physician committee meetings); and recruitment of physician mentors through a variety of means and not just through MCOS: The current goals emphasize preparing students to have a working knowledge of managed care principles and practice that can be applied in any medical field and setting. This goal contrasts with the original goal of preparing students for jobs "within" managed care. The IGC Project is viewed at Nova Southeastern as the flagship of interdisciplinary curricular changes in the training of tomorrow's physicians.

Curriculum↗
PubMed2004

A conserved transcript pattern in response to a specialist and a generalist herbivore.

Transcript patterns elicited in response to attack reveal, at the molecular level, how plants respond to aggressors. These patterns are fashioned both by inflicted physical damage as well as by biological components displayed or released by the attacker. Different types of attacking organisms might therefore be expected to elicit different transcription programs in the host. Using a large-scale DNA microarray, we characterized gene expression in damaged as well as in distal Arabidopsis thaliana leaves in response to the specialist insect, Pieris rapae. More than 100 insect-responsive genes potentially involved in defense were identified, including genes involved in pathogenesis, indole glucosinolate metabolism, detoxification and cell survival, and signal transduction. Of these 114 genes, 111 were induced in Pieris feeding, and only three were repressed. Expression patterns in distal leaves were markedly similar to those of local leaves. Analysis of wild-type and jasmonate mutant plants, coupled with jasmonate treatment, showed that between 67 and 84% of Pieris-regulated gene expression was controlled, totally or in part, by the jasmonate pathway. This was correlated with increased larval performance on the coronatine insensitive1 glabrous1 (coi1-1 gl1) mutant. Independent mutations in COI1 and GL1 led to a faster larval weight gain, but the gl1 mutation had relatively little effect on the expression of the insect-responsive genes examined. Finally, we compared transcript patterns in Arabidopis in response to larvae of the specialist P. rapae and to a generalist insect, Spodoptera littoralis. Surprisingly, given the complex nature of insect salivary components and reported differences between species, almost identical transcript profiles were observed. This study also provides a robustly characterized gene set for the further investigation of plant-insect interaction.

Animals↗
PubMed2005

The significance of facultative scavenging in generalist predator nutrition: detecting decayed prey in the guts of predators using PCR.

Gut-content analyses using molecular techniques are an effective approach to quantifying predator-prey interactions. Predation is often assumed but scavenging is an equally likely route by which animal DNA enters the gut of a predator/scavenger. We used PCR (polymerase chain reaction) to detect scavenged material in predator gut homogenates. The rates at which DNA in decaying slugs (Mollusca: Pulmonata) and aphids (Homoptera: Aphididae) became undetectable were estimated. The detectability of DNA from both carrion types in the guts of the generalist predator Pterostichus melanarius (Coleoptera: Carabidae) was then determined. The effects of carrion age and weight, as well as beetle sex, on detection periods, were quantified. Laboratory trials measured prey preference of beetles between live and decaying prey. Further experiments measured, for the first time, feeding by P. melanarius on dead slugs and aphids directly in the field. In both field and laboratory, P. melanarius preferentially fed on dead prey if available, but preference changed as the prey became increasingly decayed. Disappearance rates for slug carrion in wheat fields and grasslands were estimated and P. melanarius was identified as the main scavenger. Comparison of the retention time for dead slugs in the field, with the detection period for decaying slug material in the guts of the predators, showed that PCR-based techniques are not able to distinguish between predated and scavenged food items. This could potentially lead to overestimation of the impact of predation on slugs (and other prey) by carabids. Possible implications of facultative scavenging by invertebrate predators for biocontrol and food-web research are discussed.

Animals↗
PubMed2005

Detection of secondary predation by PCR analyses of the gut contents of invertebrate generalist predators.

Predation by generalist predators is difficult to study in the field because of the complex effects of positive and negative interactions within and between predator species and guilds. Predation can be monitored by molecular means, through identification of prey DNA within predators. However, polymerase chain reaction (PCR) amplification of prey DNA from predators cannot discriminate between primary and secondary predation (hyperpredation), in which one predator feeds on another that has recently eaten the target prey. Here we quantify, for the first time, the potential error caused by detection of prey DNA following secondary predation, using an aphid-spider-carabid model. First, the aphid Sitobion avenae was fed to the spider Tenuiphantes tenuis and the carabid Pterostichus melanarius, and the postconsumption detection periods, for prey DNA within predators, were calculated. Aphids were then fed to spiders and the spiders to carabids. Aphid DNA was detected in the predators using primers that amplified 245- and 110-bp fragments of the mitochondrial cytochrome oxidase I gene. Fragment size and predator sex had no significant effect on detection periods. Secondary predation could be detected for up to 8 h, when carabids fed on spiders immediately after the latter had consumed aphids. Beetles tested positive up to 4 h after eating spiders that had digested their aphid prey for 4 h. Clearly, the extreme sensitivity of PCR makes detection of secondary predation more likely, and the only reliable answer in future may be to use PCR to identify, in parallel, instances of intraguild predation.

Animals↗
PubMedDate not supplied

Use of PHN competencies and ACHNE essentials to develop teaching-learning strategies for generalist C/PHN curricula.

This paper provides a useful tool for the undergraduate community/public health nursing (C/PHN) faculty member to design courses and learning activities, and to interpret C/PHN education needs to undergraduate curriculum committees and administrators. Specifically, this paper provides a tangible bridge between the Public Health Nursing Competencies (Quad Council of Public Health Nursing Organizations, 2004) and the Association of Community Health Nursing Educators (ACHNE) Essentials of Baccalaureate Education (2000) for both didactic and clinical learning experiences. The tables may be used in multiple ways, including curriculum monitoring and improvement, course development and instructional design, clinical practice planning, and as a foundation for evaluation of conceptual learning and practice competence for the C/PHN generalist. Because C/PHN experiences in undergraduate education are unique and context based, the tables exemplify how two key guiding documents mutually frame the C/PHN educational experience supported by specific learning activities. Further, at a minimum, MSN preparation as a C/PHN specialist is clearly necessary for the teaching and learning of baccalaureate curricular components of C/PHN.

Case Management↗
PubMed2006

Effect of the inpatient general medicine rotation on student pursuit of a generalist career.

BACKGROUND: Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain. OBJECTIVE: To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM. DESIGN: Multicenter cohort study. PARTICIPANTS: Third-year medical students between July 2001 and June 2003. MEASUREMENTS: End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of "Very Likely" or "Certain" to the question "How likely are you to pursue a career in GIM?"; and (2) entry into an internal medicine residency using institutional match data. RESULTS: Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01). CONCLUSIONS: Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.

Career Choice↗
PubMed2000

Educating generalist physicians for rural practice: how are we doing?

Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to "small rural" communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.

Career Choice↗
PubMed1988

Variation in neuromuscular activity during prey capture by trophic specialists and generalists (Pisces: Labridae).

Members of the marine teleost family Labridae are among the most abundant and morphologically diverse fish on coral reefs. A quantitative analysis was conducted of the neuromuscular activity patterns controlling movement of the jaws during prey capture by 4 labrid species ranging from trophic specialists to trophic generalists. A total of more than 800 captures of 3 prey types was analyzed. All 4 species showed significant modulation of electromyographic parameters in response to different prey types. Significant variation was also found between replicate experiments on the same individuals. To obtain valid assessments of interspecific variability, statistical analyses must take into account this potentially high degree of intraspecific variability. By partitioning the variance in a nested analysis of variance, a lack of significant differences in electromyographic parameters between species became apparent. In contrast to the closely related Cichlidae, trophic diversification in the Labridae has not been accompanied by the acquisition of unique neuromuscular activity patterns for prey capture. The dramatic adaptive radiation that has occurred in these 2 families has involved different processes of evolutionary diversification. Neuromuscular stereotypy of labrids may be associated with the lack of structural flexibility in their 'coupled jaw'. Additional study is needed to establish the extent to which labrid radiation into various trophic niches is related to the evolution of specialized morphologies and foraging behaviors.

Animals↗
PubMed2002

Grade-induced beliefs about undergraduate generalist social work practice competency.

Standardized criterion-referenced achievement testing of undergraduate generalist social work knowledge based on correct answers to specific questions is compared to several norm-referenced measures of student learning, including student self-reports and the instructor-imposed cumulative grade point average (GPA). Two hypotheses are tested, namely, (a) norm-referenced measures systematically overstate content knowledge, and (b) student perception or belief about the ascribed meaning of the GPA inflates self-rated attainments. The implications of additional confirming evidence for the hypotheses are explored with a view to limiting the number of social workers with undergraduate degrees who are permitted to enter the field each year overconfident about their knowledge and practice capabilities.

Adult↗
PubMed2003

Differential adoption of pharmacotherapy recommendations for type 2 diabetes by generalists and specialists.

Newer, multimedication (novel) regimens provide better glycemic control for many type 2 diabetics when sulfonylurea monotherapy (traditional) becomes ineffective. Because better glycemic control is associated with decreased likelihood of complications and lower utilization and cost of care, the authors examined change in prescribing patterns for veterans with type 2 diabetes between FY 97 and 99. They classified medication regimens as traditional and novel based on the combination of diabetes medications patients received at the end of each year. Multivariate logistic regression analyses controlling for disease severity indicated that patients were more likely to receive novel regimens over time, but those seen only in primary care were less likely to receive novel regimens than those previously seen by a specialist. Geographic differences and differences in how recommendations were implemented by generalists and specialists suggest that diffusion of innovations theory may help explain variations in practice and guide interventions designed to translate research into practice.

Aged↗
PubMed2006

Can a GP be a generalist and a specialist? Stakeholders views on a respiratory General Practitioner with a special interest service in the UK.

BACKGROUND: Primary care practitioners have a potentially important role in the delivery of specialist care for people with long-term respiratory diseases. Within the UK the development of a General Practitioner with Special Interests (GPwSI) service delivered within Primary Care Trusts (PCTs) involves a process of 'transitional change' which impacts on the professional roles of clinicians who may embrace or resist change. In addition, the perspective of patients on the new roles is important. The objective of the current study is to explore the attitudes and views of stakeholders to the provision of a respiratory GPwSI service within the six PCTs in Leicester, UK. METHODS: Using a qualitative design, GPs, nurses, secondary care doctors, nurse specialists, physiotherapists, a healthcare manager and patients with respiratory disease took part in focus groups and in-depth interviews. RESULTS: The 25 participants expressed diverse opinions about the challenge of integrating specialist services with generalist care and the specific contribution that GPs might make to the care of people with chronic respiratory disease. A range of potential roles for a respiratory GPwSI, working as part of a multi-disciplinary team, were suggested, and a number of practical issues were highlighted. Success of the GPwSI role is deemed to be dependent on having the trust of their primary and secondary care colleagues as well as patients, credibility as a practitioner, and being politically astute thereby enabling them to act as a champion supporting the transition process within the local health service. CONCLUSION: The introduction of a respiratory GPwSI service represents a challenge to traditional roles which, whilst broadly acceptable, raised a number of important issues for the stakeholders in our study. These perspectives need to be taken into account if workforce change is to be successfully negotiated and implemented.

Attitude of Health Personnel↗
PubMed1998

Ischemic stroke: outcomes, patient mix, and practice variation for neurologists and generalists in a community.

A variety of methods was used to compare patient mix, practice variation, survival, and recurrence after first ischemic stroke among Rochester, MN residents. The significance of the results for neurologists and generalists was examined. Age, stroke severity, congestive heart failure (CHF), and the interaction between atrial fibrillation and patient groups were determinants of survival. Without atrial fibrillation, patients on neurology services and patients on general services with neurology consultation had better survival than those without neurology consultation, adjusting for age, stroke severity, and CHF. With atrial fibrillation, patients on general services with neurology consultation had no better survival compared with those without neurology consultation; patients on neurology services had worse survival (p=0.002). There was no difference in stroke recurrence. Evaluation by a neurologist is associated with better survival for most patients with ischemic stroke but not those with atrial fibrillation. Only a randomized trial can determine whether this association is causal.

Adult↗
PubMed2005

Bridging the specialist-generalist divide: a creative Master's programme initiative.

This article outlines the development of a new Master's programme that is suitable particularly for those who are interested in managing palliative care in generalist care contexts. Disseminating the essence of excellent palliative care provision, accessible by the minority to the majority in need, has been an issue for some time. National Service Frameworks identify the contribution of both education and workforce planning to facilitate such provision. A gradual shift in design of palliative programme provision has seen the emergence of education that is more malleable to varied practice contexts. This new MSc Palliative Care Programme is centred on interprofessional education, and through collaborative working, shares modules with a neighbouring university to produce financially viable provision. Essential palliative content is delivered in compulsory taught modules, however, elective options include open or work-based modules that facilitate palliative practice development tailored to specific context need. Postgraduate study, associated with leading practice, means that a few key staff can significantly impact disseminating enhanced palliative practice across care environments. In this way, in the community and in institutions where the majority of older people dying of chronic illness are cared for, resources can be used purposefully to maximize the chance of 'a good enough death' (McNamara, 2001).

Curriculum↗