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PubMed2005

Clinical geropsychology training in generalist doctoral programs.

While a relatively small number of clinical psychology graduate programs offer specialized tracks in clinical geropsychology, the need for psychologists trained to work with older adults is increasing. This paper presents a model of training that could be adopted by generalist training programs to better prepare their students to work with older adults without creating a specialty program in geropsychology. The model identifies key domains of knowledge that should be covered, emphasizes service learning as a key element of training, provides a list of resources for faculty desiring to develop a geropsychology course, and suggests ways to overcome barriers that may prevent the implementation of the model.

Aged↗
PubMedDate not supplied

Family medicine's identity: being generalists in a specialist culture?

Family medicine has been in conflict about whether it is a specialty or a generalist discipline. Although for a time the family was offered as a solution to family medicine being marginalized in biomedicine, a more biomedical focus prevailed. As a result, the practice of family medicine came more to resemble the world of biomedicine despite an insistence on the discipline's distinctiveness. Ways to avoid identity pitfalls in the future might be to seek solutions that do not promise to solve our identity problem once and for all, to refrain from adopting generalized slogans that do not encourage critical thinking, to practice what we preach, to accept that specialization is part of the American cultural ethos, and to embrace reflective practice.

Culture↗
PubMed1998

Specialists achieve better outcomes than generalists for lung cancer surgery.

OBJECTIVE: A push toward care provided by generalists as opposed to specialists has occurred in the health-care marketplace despite a lack of provider specific outcome data. The objective of this study was to determine whether the outcome of patients undergoing lung cancer surgery is different between general surgeons (GSs) and thoracic surgeons (TSs). DESIGN: Examination of data from a state-wide severity-adjusted administrative hospital discharge database. SETTING/PARTICIPANTS: Patients undergoing lung cancer resection in all nonfederal acute care hospitals within South Carolina. MAIN OUTCOME MEASURES: Mortality by specialty adjusted for case mix. RESULTS: From 1991 to 1995, 1,720 resections for lung cancer were performed in South Carolina. One hundred thirty-seven cases were excluded because surgeons did not meet the predefined criteria for board certification, leaving 1,583 resections for analysis. One-half of lobectomies and nearly 60% of pneumonectomies were performed by GSs. Patients were similar in age, sex, gender, race, and the proportion in each severity of illness subclass. Mortality was significantly higher in patients who underwent lobectomy by GSs vs TSs (5.3% vs 3.0%; p<0.05) and in patients with extreme comorbidities (43.6% vs 25.4%; p=0.03) or age >65 years (7.4% vs 3.5%; p<0.05). Seventy percent of TSs performed > 10 cases in the series, whereas 75% of GSs performed <10 (p=0.05). Logistic regression analysis failed to identify any significant variable that might explain the mortality differences between TSs and GSs. CONCLUSION: Mortality is lower for lung cancer resection when the surgery is performed by a TS.

Female↗
PubMed2001

Pediatric generalists and subspecialists: determinants of career satisfaction.

OBJECTIVES: To evaluate the work life and job satisfaction of pediatric generalists and subspecialists in comparison to each other and to a group of general internists and internal medicine subspecialists. METHODS: Data were collected by survey of a national sample of 5704 general pediatricians, subspecialty pediatricians, general internists, internal medicine subspecialists, and family physicians who were selected randomly from the American Medical Association Masterfile using stratified sampling with disproportionate weighting to ensure ethnic diversity and representation of high managed care areas. Surveys were mailed up to 4 times and contained 150 items that reflected 10 facets of physician job satisfaction as well as an assessment of individual and practice demographic information. This study reports data from all groups except for family medicine. RESULTS: The adjusted response rate was 58% for general pediatricians (n = 590), 67% for specialty pediatricians (n = 345), and 52% (n = 1823) for the entire pool. In comparison with general internists, general pediatricians were more likely to be female (44% vs 24%); to work part time (20% vs 12%); to have lower annual income ($125 679 vs $143 875); and to report significantly higher levels of job, career, and specialty satisfaction on a 5-point scale (3.81 vs 3.52, 3.80 vs 3.55, and 3.76 vs 3.17 respectively). In comparison with internal medicine subspecialists, pediatric subspecialists were more likely to be female (42% vs 22%); to work in academically affiliated settings (35% vs 17%); to have lower incomes ($156 284 vs $192 006); to receive significantly less time for a complete history and physical examination (39 minutes vs 51 minutes); and to report similar levels of job, career, and specialty satisfaction (3.69 vs 3.71, 3.74 vs 3.78, and 3.60 vs 3.47 respectively). Of all 4 physician groups, general pediatricians worked the fewest hours (50/week), spent the greatest percentage of time in the office and the lowest percentage in the hospital (58% and 16%, respectively), saw the lowest percentage of patients with complex medical and complex psychosocial problems (15% and 17%, respectively), and were the least likely to endorse symptoms of burnout or job stress (13% and 18%, respectively). In comparison, pediatric subspecialists worked longer hours (59/week), spent the lowest percentage of time in the office and the greatest percentage of time in the hospital (22% and 44%, respectively), saw a much higher percentage of patients with complex medical and complex psychosocial problems (46% and 25%, respectively), and reported significantly higher levels of burnout and job stress (23% and 26%, respectively). CONCLUSIONS: Despite lower incomes, general pediatricians reported the highest levels of satisfaction and the least job stress of all 4 physician groups, whereas pediatric subspecialists reported levels of stress and burnout that raise significant concerns for the workforce of pediatric subspecialists of the future. Initiatives that improve clinical workload, balance inpatient and outpatient hours, and increase personal time of pediatric subspecialists should be considered.

Burnout, Professional↗
PubMed2006

Implicating an introduced generalist parasitoid in the invasive browntail moth's enigmatic demise.

Recent attention has focused on the harmful effects of introduced biological control agents on nontarget species. The parasitoid Compsilura concinnata is a notable example of such biological control gone wrong. Introduced in 1906 primarily for control of gypsy moth, Lymantria dispar, this tachinid fly now attacks more than 180 species of native Lepidoptera in North America. While it did not prevent outbreaks or spread of gypsy moth, we present reanalyzed historical data and experimental findings suggesting that parasitism by C. concinnata is the cause of the enigmatic near-extirpation of another of North America's most successful invaders, the browntail moth (Euproctis chrysorrhoea). From a range of approximately 160,000 km2 a century ago, browntail moth (BTM) populations currently exist only in two spatially restricted coastal enclaves, where they have persisted for decades. We experimentally established BTM populations within this area and found that they were largely free of mortality caused by C. concinnata. Experimental populations of BTM at inland sites outside of the currently occupied coastal enclaves were decimated by C. concinnata, a result consistent with our reanalysis of historical data on C. concinnata parasitism of the browntail moth. The role of C. concinnata in the disappearance of browntail moth outside these enclaves has not been reported before. Despite the beneficial role played by C. concinnata in reversing the browntail moth invasion, we do not advocate introduction of generalist biological control agents. Our findings illustrate that the impact of such organisms can be both unpredictable and far-reaching.

Animals↗
PubMed1995

State legislative strategies to improve the supply and distribution of generalist physicians, 1985 to 1992.

State laws enacted between 1985 and 1992 were reviewed to examine state involvement in influencing the supply and distribution of generalist physicians. Forty-seven states enacted 238 relevant laws during this period. In 1991 and 1992, 36 states enacted 98 laws, as compared with 1985 and 1986, when 8 states enacted 12 laws. Legislation addressed planning and oversight; financial incentives to institutions, students, and residents; and strategies to enhance the practice environment. A new strategy is to link funding to measureable outcomes, such as the career choices of a state medical school's graduates. Few states devoted resources to evaluate their efforts.

Education, Medical↗
PubMed1997

Advanced education for the role of rural nurse generalist.

The Montana State University College of Nursing has developed a master's degree program which prepares nurses as generalists with advanced knowledge for understanding and addressing rural health care needs. The programs is clear about its goals and objectives and does not attempt to be "all things for all people." The emphasis is on rural nursing, and this emphasis is present in recruiting, teaching, research and publication at the College. Classroom and clinical experiences challenge students to develop a broad range of skills, and most importantly to enhance critical thinking and problem-solving abilities. Since delivering high quality health care in rural areas requires the ability to understand health care from the consumer's perspective, both data collection and clinical experience in rural communities are required. The enthusiasm for rural nursing--practice, teaching and research--displayed by faculty members, alumnae and students is both a major factor in, and an indication of, the program's success.

Clinical Competence↗
PubMed1996

Primary care: specialists or generalists.

A critical appraisal of the literature on the cost and quality trade-offs of primary care provided by specialists in comparison with that provided by generalists is presented.

Continuity of Patient Care↗
PubMed1990

Expectations and outcome skills of a generalist health care administrator.

The question of the degree of technical versus managerial competence to be found in future graduates from health administration programs is not easily resolved. In the HIMSS 1988 survey of CIOs the attributes needed for success are listed in descending rank order as follows: leadership ability, vision/imagination, knowledge of hospital systems, business acumen, decisiveness, and technical competence. CIOs ranked technical competence as less important than other attributes associated with general management success. The expectations for attitudes, knowledge, and skills presented in this article support the greater importance of management abilities relative to pure technical competence. However, it is vital that an appropriate level of technical knowledge and skill be maintained to enable future alumni of health administration programs to function effectively as administrators. Depending on their role in a health care organization, greater or lesser technical knowledge may be needed. Those pursuing a career path toward CIO must, of necessity, have greater technical knowledge and skill. We have discussed necessary and expected attitudes, knowledge, and skills that will be needed by the generalist health administration graduate in the future. It will be important to develop and maintain an attitude that MIS is a strategic tool, that health care technology is a corporate asset, and that information is power. Graduates must recognize the necessity of maintaining and enhancing their knowledge and skills through continuing education. The knowledge base of MIS education should focus on determining information needs to support strategic goals, understanding of general systems theory, principles of systems analysis, design, implementation and maintenance, awareness and exposure to standard application software, and an awareness of external sources of data.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer Literacy↗
PubMed1993

Why not a nurse as a general health service executive? Influences and constraints on the change to a generalist career by nurse managers.

Twenty-three generalist health managers in Australia who have made a career path change from management in the nursing division were surveyed about factors which they perceived as either promoting or constraining their changes in career path. The most significant influencing factors were determination to succeed, personal skills and abilities, the ability to work as part of a team and track record, with ten factors being rated overall as 'quite important'. The most constraining factors related to the shortage of management positions, turbulence in the health care industry, and political factors connected with the mechanisms for making executive appointments.

Adult↗
PubMed2005

Cryptic speciation and host-race formation in a purportedly generalist tumbling flower beetle.

Host-race formation remains controversial as a source of herbivorous insect diversity, and examples of host races are still fairly scarce. In this study, analysis of five enzyme loci in the ostensibly generalist tumbling flower beetle Mordellistena convicta (Coleoptera: Mordellidae) revealed hidden host-plant and plant-organ related genetic differentiation. Mordellistena convicta turned out to be a complex of cryptomorphic species, each with fewer hosts than the nominal species. These cryptic species, in turn, were divided into taxa that showed host-race characteristics: samples from different host plants and organs exhibited (1) genetic indications of partial reproductive isolation, (2) differences in size and emergence timing that suggested divergent host-related selection, and (3) among-host selective differences in mortality from parasitoids. Host-race formation in M. convicta, which has a somewhat different life history from the well-studied host races, enlarges the group of insects considered likely to undergo this process. The widespread sympatry of the M. convicta species complex, along with its spectrum of host-correlated genetic differentiation, suggests that these host specialist taxa developed in sympatry.

Adaptation, Biological↗
PubMed1988

[The internist--generalist or specialist?].

Also after the elimination of certain subjects and after the development of subspecialisations internal medicine has remained the central clinical basic speciality. The synoptic medical thinking and acting with a coordination of all special examinations to a coherent view and treatment of the patients is incumbent on the internal specialist as "general internal specialist" or so-called "generalist". The central point of the intermedical care of the population lies in the work of the internal specialist. This has consequences also for the education and further training. In the auditory and at the patient we must be able to show the students and physicians trustworthy how internal medicine as general internal medicine is organised in its full extent and is practised by a medical superintendent who is qualified to do this.

Education, Medical, Continuing↗
PubMed1995

Special article: increasing the number of generalist physicians--a new regulatory paradigm.

Increasing the number of generalist physicians has become a major component of health system reform proposals. This change in physician manpower may be attempted by educational approaches, market-driven responses, or regulatory requirements. Regulatory approaches may be considered in the broad contexts of public policy models. Two such models considered in this essay include 1) the acceptance of health care as a positive claim right that places the responsibility for providing health care on the state, and 2) a shift in the role of government in general from reacting to public concerns to activity shaping them. Each results in a greater governmental, regulatory intervention on medical manpower planning. As these policy constructs gain or lose force or favor, so too will their impact on medical education.

Family Practice↗
PubMed1994

Implications of generalists' slow adoption of zidovudine in clinical practice.

BACKGROUND: The lag time for adoption of new acquired immunodeficiency syndrome (AIDS) therapies into the clinical practices of different types of ambulatory care providers can be estimated from patient use of zidovudine therapy during the first few years after approval by the Food and Drug Administration. METHODS: We analyzed receipt of zidovudine therapy from April 1987 through March 1990 by 3643 patients with a diagnosis of AIDS. The study group was continuously enrolled in the New York State Medicaid program for at least 6 months after diagnosis. For each patient, the dominant providers of ambulatory care, receipt of zidovudine therapy, and consultation with a human immunodeficiency virus-AIDS specialist within 6 months after diagnosis were determined from Medicaid claims. AIDS specialists included physicians or clinics specializing in infectious disease or hematology/oncology or specific clinics within designated AIDS centers. RESULTS: In 1987, 55% of those who had an AIDS specialist as their dominant care provider received zidovudine therapy, compared with only 36% of patients with a primary care clinic as their dominant care provider. It was not until 1990, 3 years after approval by the Food and Drug Administration, that the percentage of patients receiving zidovudine therapy (77% to 78%) was comparable for patients of primary care clinics and AIDS specialists. In logistic regression analysis, zidovudine use did not differ between patients of AIDS specialists and patients with other types of dominant providers when the latter group had consulted with an AIDS specialist (adjusted odds ratio, 1.38; 95% confidence interval, 0.99 to 1.95). CONCLUSIONS: In our AIDS study population, there was at least a 3-year lag before patients of primary care clinics received zidovudine therapy at the same rate as patients of AIDS specialists. Conditions such as AIDS with rapid changes in treatment options may require a close relationship between generalists and specialists to increase access to new therapies.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Generalist model of case management practice.

There has been a renewed interest during the past few decades in formalizing the use of case management in the fields of education, health, mental health, and human services. This article presents a generalist model of case management practice including 11 functions that are performed by case managers in many settings where case management is practiced. Several factors suggest that in the future the role played by case managers will become increasingly significant in assuring that clients receive quality services. The forces of program accountability, resource limitations, and client demands for services will intensify the need for developing case management practice models.

Forecasting↗
PubMedDate not supplied

Required first-year generalist clinical experience courses and their relationship to career choice: the critical effect of family medicine involvement.

BACKGROUND: This study examines the relationships among the presence of a required first-year generalist clinical experience (RFGCE) course, family medicine involvement in such courses, and the percentage of 1993 medical school graduates who chose family practice as a career upon graduation. METHODS: A prospective cohort study measured predictor variables in 1989, the presence of a required third-year family medicine clerkship in 1991, and the outcome variable in 1993. RESULTS: Data were collected from 122 US 4-year medical schools. Eighty-seven (71.3%) of 122 medical schools had RFGCE courses. In schools with courses and family medicine administrative units, family physicians were involved to some extent in most of these courses (88%). After controlling for type of medical school, the requirement of a third-year family medicine clerkship, and the involvement of a family medicine administrative unit, the presence of an RFGCE course was associated with a 3.5% increase in the number of students who selected a family practice career. This is a 28% increase on average over the mean percentage of medical students choosing a family practice career in 1993. However, in a second analysis, when all predictor variables were entered into the equation, family medicine involvement in such courses replaced the presence of such courses as a statistically significant predictor of medical students selecting family practice as a career. CONCLUSIONS: Family physicians are involved to some extent in the great majority of RFGCE courses. Such involvement is associated with an increase in the number of medical students selecting a family practice career upon graduation from medical school.

Career Choice↗
PubMed1998

The community continuity experience: generalist training for preclinical medical students.

Many medical schools are planning community-based experiences for preclinical students. In August 1994, The University of Texas Medical Branch at Galveston began placing all 200 first-year medical students in generalists' offices in a new course called the Community Continuity Experience. The office nurse served as site facilitator. Activities during the second term provided more opportunities for students to interview patients as well as to observe the site physicians. The course committee used feedback from student evaluations and focus groups to change the implementation of the curriculum. We found that nurses as site facilitators effectively managed the students' activities, that continuity of site was more important to students than breadth of exposure, that the optimum focus of activities was the examination room, that training in actual skill development (e.g., methods of patient education) was desired before site activities, and that careful integration of preclinical patient-oriented courses was important to expose students to a coherent approach to learning skills for patient assessment.

Attitude of Health Personnel↗
PubMed1998

Specialist registrar training and the generalist: views of trusts and health authorities.

As a results of the introduction of structured training in postgraduate medical education we undertook a survey of North Thames stakeholders in health authorities and trusts to ascertain views on the implications of the specialist registrar grade on the future shape of the clinical workforce. Trusts and health authorities expressed concern over the training of specialist doctors at the expense of training generalists to provide patient care.

Attitude of Health Personnel↗