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PubMed1994

Medical school and student characteristics that influence choosing a generalist career.

OBJECTIVE: To identify predictors in medical schools that can be manipulated to affect the proportion of graduates entering generalist practice. DESIGN AND PARTICIPANTS: Cross-sectional and retrospective studies of medical schools and practicing generalist physicians; surveys of MD-granting and DO-granting medical schools; site visits to nine schools with a high proportion of graduates becoming generalist physicians; surveys of national samples of MD and DO generalist physicians. INDEPENDENT VARIABLES: Characteristics of medical schools, including structural characteristics, financing, mission, admissions policies, student demographics, curriculum, faculty, and the production of generalist physicians; information on personal characteristics, background, perceptions, and attitudes of practicing generalist physicians. DEPENDENT VARIABLE: Estimated proportion of graduates of the classes of 1989, 1990, and 1991 in family practice, general internal medicine, and general pediatrics. RESULTS: Institutional mission, certain admissions policies, characteristics of entering students, and the presence of a primary care-oriented curriculum explained statistically significant variation in the number of physicians choosing generalist careers, even after the structural characteristics of public or private status, age of the school, and class size were controlled for statistically. CONCLUSIONS: Public and institutional policies, where implemented, have had a positive effect on students' choice of generalist careers. The most influential factors under the control of the medical school are the criteria used for admitting students and the design of the curriculum, with particular emphasis on faculty role models. Personal social values was the individual characteristic that most strongly influenced graduates' career choice.

Career Choice↗
PubMed2007

A comparison of outcomes resulting from generalist vs specialist care for a single discrete medical condition: a systematic review and methodologic critique.

BACKGROUND: Studies of clinical outcomes for generalist vs specialist care for diagnoses within a specialist's narrow domain have tended to favor specialty care. METHODS: A MEDLINE search from January 1, 1980, through April 1, 2005, and a hand search of retrieved bibliographies of English-language studies that compared generalist vs specialist care for individual patients with a single discrete medical condition were performed. Two reviewers determined eligibility for each study and abstracted data onto a standardized instrument. RESULTS: A total of 49 articles met our inclusion criteria: 24 studies favored specialty care, 13 found no difference in outcomes, 7 varied by individual outcome, 1 depended on physician experience, and 4 favored generalist care. Only 8 studies reported integration into health delivery systems, 4 considered physician experience, 3 documented information technology support, and 2 considered the impact of care management programs. Selection bias was adequately addressed in 58% of studies that favored specialty care and in 71% of studies that found no difference or favored generalist care (P = .52). Studies that favored specialty care were less likely to consider 4 key, potentially confounding physician or practice characteristics compared with studies that found no difference or favored generalist care (3% vs 15% of potential instances, respectively; P = .009). CONCLUSIONS: The literature regarding the influence of generalist vs specialist care on outcomes for patients with a single discrete condition suffers from important methodologic shortcomings. Further research is needed to inform health care policy as it pertains to the optimal role of generalists and specialists in the physician marketplace.

Clinical Competence↗
PubMed1998

A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

PURPOSE: Both generalist and pulmonologist physicians care for patients with severe chronic obstructive pulmonary disease (COPD). We studied patients hospitalized with severe COPD to explore whether supervision of care by pulmonologists is associated with greater costs or better survival. SUBJECTS AND METHODS: We studied 866 adults with severe COPD enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a prospective study at five academic medical centers. Patients were admitted to the hospital or transferred to an intensive care setting for treatment of severe COPD, defined by hypoxia (PaO2 <60 mm Hg) and hypercapnia (PaCO2 >50 mm Hg) or hypercapnia alone if on supplemental oxygen. Resource intensity was measured using a modified version of the Therapeutic Intervention Scoring System and estimated hospital costs. To account for differences in the patient case mix, propensity scores were developed to represent each patient's probability of having a pulmonologist as attending physician and each patient's probability of being in an intensive care unit (ICU) at study admission. RESULTS: Of the 866 patients studied, 512 had generalists and 354 pulmonologists as their attending physicians. The median patient age was 70 years; 52% were male; 14% died within 30 days. After adjusting for baseline differences in patient characteristics, there were no differences in resource intensity and hospital costs in those treated by pulmonologists or generalists. Adjusted average resource intensity scores for the entire hospitalization were 16.5 for pulmonologists and 17.0 for generalists (P = 0.34). Estimated hospital costs were the same ($6,400) for patients treated by pulmonologists and generalists (P = 0.99). Patients with pulmonologists as attending physicians did not experience better survival. Comparing patients of pulmonologists to patients of generalists, the adjusted hazard ratio for 30-day mortality was 1.6 (95% confidence interval: 0.98, 2.5); the hazard ratio for 180-day mortality was 1.2 (0.9, 1.7). CONCLUSIONS: Our findings suggest that for patients hospitalized with exacerbation of severe COPD, those with pulmonologist attending physicians do not have higher hospital resource use or better survival than those with generalist attending physicians.

Adult↗
PubMed1996

Determinants of the generalist career intentions of 1995 graduating medical students.

Using national databases of the Association of American Medical College, the authors employed logistic regression analysis to show the relative predictive influences of selected demographic, structural, attitudinal, and educational variables on the specialty careers choices of 1995 U.S. medical school graduates. Plans to pursue certification in family practice or an unspecified generalist career could be predicted with moderate success, while choices of general internal medicine and general pediatrics could not. The intentions of the 1995 graduates to pursue generalist specialty, were significantly associated with demographic factors such as female gender, older student age, and rural hometown; early interest in the generalist specialties; attitudes favoring helping people over seeking opportunities for leadership, intellectual challenge, or research; the presence of a department of family medicine in the medical school; and ambulatory care experiences in the third and fourth years. In the multiple-regression models used in this study, a number of factors widely touted as important to the cultivation of generalism were not significant predictors of generalist decisions; an institutional mission statement expressly addressing the cultivation of generalist careers; giving admission preferences to applicants who vowed an interest in generalism; public (versus private) school sponsorship; discrete organization units for general internal medical or general pediatrics; the proportion of institutional faculty in the general specialty of medicine and pediatrics; the level of educational debt; the students; clinical experiences in the first and second years of medical school. The authors acknowledge the danger of inferring causal relationships from analyses of this kind, and described how the power of previous associations--e.g., that between a required third-year clerkship in family medicine and graduates' family practice career choices--may be weakened when the independent variable spreads across institutional cultures that at present are less conductive to primary care. The findings of this analysis add to the evidence that generalist career intentions are largely carried on the tide of students' interests and experiences in family medicine and ambulatory primary care. In terms of the predictive values of the input variable in this study, career decisions for the other two generalist specialties--general internal medicine and general pediatrics--were essentially a crapshoot, either because the tactics to promote interest in these fields were ineffective (or confounded), or because the efforts were underdeveloped. Moreover, the statistical models of this study employed quantifiable variables that can be discerned and manipulated to guide the result, whereas medical students tend to identify less tangible elements as more powerful factors influencing their career choices. The results sharpen the strategic focus, but must be combined with those of other, descriptive analysis for a more complete understanding of graduating students' career decisions.

Adult↗
PubMed1997

Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative.

The Generalist Physician Initiative (GPI) was created by The Robert Wood Johnson Foundation to help medical schools increase the number of predoctoral and residency graduates entering generalist careers. The underlying assumption of the GPI is that more medical graduates will become generalists if schools select candidates whose personal characteristics are compatible with generalist careers and if schools provide for them an educational environment that values generalist careers in the same manner it has valued specialist careers. In essence, the GPI is helping schools modify the culture in which medical education occurs so that they may increase their production of generalists. Fourteen grants for six years of support were made to 16 U.S. medical schools in 1994. These schools are developing institution-wide efforts that span the continuum from the recruitment and selection of students through their medical school and residency education to their entry into practice, and include support of the practice. Most schools have developed external partners (e.g., state legislatures, managed care organizations, area health education centers) to assist in achieving their goals. The project is now (1997) at its halfway mark. This article describes the conceptual bases for the program (e.g., changes in admission criteria to favor applicants oriented to generalism), identifies common approaches to intervention chosen by the participating schools (e.g., establishing longitudinal, generalist-oriented clinical experiences throughout the four years of medical school), and explores issues being faced by the schools as they implement change (e.g., difficulties in decentralizing clinical education to include community physicians as teachers and role models).

Career Choice↗
PubMed1999

Increasing recruitment contacts between generalist residents at the Medical College of Georgia and rural and underserved communities.

To increase the number of residents choosing to practice in rural and underserved areas, the Medical College of Georgia in 1994 created the Office of Recruitment and Retention (ORR) for generalist physicians as part of its participation in The Robert Wood Johnson Foundation's Generalist Physician Initiative. Its major purpose is to increase the contact between generalist residents and practice opportunities, especially those in rural and underserved areas. The office has helped residents better understand the resources available in rural settings and has helped these communities better understand the needs of graduates in generalist residency programs. It became a point of contact for residents and communities. It also organized on-campus "practice opportunity fairs" that permitted community representatives to meet formally with generalist residents to provide information on practice opportunities and community resources. The office organized practice management sessions and provided legal consultation to residents desiring to enter private practice in rural settings. This program has already been instrumental in furthering contact between generalist residents and the rural communities they selected as clinical practice sites during training. Although it is too early to know the impact of these activities, communities increasingly use the office to recruit generalist physicians, and residents use it to identify appropriate practice sites.

Career Choice↗
PubMed2001

From the primary care organizations consortium's proposal to the Interdisciplinary Generalist Curriculum Project.

The Interdisciplinary Generalist Curriculum (IGC) Project was one element of an overall federal government strategy designed to promote primary care education. This project, undertaken by the Division of Medicine and Dentistry (DMD), Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, was the first large-scale medical education contract initiated by DMD. The IGC Project was based on a model proposed by the Primary Care Organizations Consortium (PCOC). The PCOC thesis was that "if students are to decide to pursue a generalist career they must have the opportunity to be taught by generalists." The PCOC Program required an explicit curriculum focusing on generalist knowledge and skills with an emphasis on technology, in the context of education that required training in ambulatory office-based settings. The PCOC Program specified that responsibility for the program's planning, implementation, and evaluation be shared by the three generalist physician faculties of family medicine, general internal medicine, and general pediatrics. In implementation of this demonstration project in ten medical schools across the nation, several lessons have been learned relative to enhancement of generalist education. Among these lessons is that seed money targeted to initiate modest change can act as a catalyst and improve the knowledge and skills afforded medical students concerning generalist practice. Limited funds provided over a sufficient period of time can induce schools to undertake significant curricular change.

Curriculum↗
PubMed2007

Use of generic cardiovascular medications by elderly Medicare beneficiaries receiving generalist or cardiologist care.

BACKGROUND: Elderly Medicare beneficiaries can reduce out-of-pocket spending and increase their options for low-cost Medicare Part D plans by using generic drugs. Physicians play a key role in determining use of generics and specialty may be a particularly influential factor. OBJECTIVES: We sought to compare generic cardiovascular drug use by older adults receiving cardiologist and generalist care. RESEARCH DESIGN: We undertook a cross-sectional analysis of data from the nationally representative Medicare Current Beneficiary Survey. Included were community-dwelling adults 66 years of age or older with hypertension, coronary disease, or congestive heart failure, one or more Medicare Part B claims for outpatient visits with generalists (internist or family practitioner) or cardiologists, using one or more cardiovascular drug available in both brand-name and generic formulations (n = 1828). MEASURES: The primary outcome was use of one or more generic medication aggregated across 5 drug classes: beta-blockers, thiazides, calcium channel blockers (CCB), angiotensin-converting enzyme (ACE) inhibitors, and alpha1-adrenergic receptor antagonists. Within-class generic use also was examined. The main independent variable was cardiologist (20.7%) versus generalist-only care (79.3%). RESULTS: In the aggregate, fewer individuals under cardiologist care used generics compared with generalist-only care (75% vs. 81%, P = 0.03; adjusted relative risk 0.89, 95% confidence interval = 0.79-0.99). Overall use of generic beta-blockers was 86.6%; thiazides, 92.0%; ACE inhibitors, 59.0%; CCB, 55.5%; alpha-blockers 47.7%. In adjusted analysis, generic CCB use occurred 34% less often among cardiologist versus generalist-only patients. CONCLUSIONS: Older patients of generalists and, to a greater extent, cardiologists, often use brand-name drugs when generic equivalents are available. Promoting generic prescribing among specialists and generalists may increase opportunities for patients and third-party payers to reduce spending on prescription drugs.

Aged↗
PubMedDate not supplied

Facilitating collaboration among academic generalist disciplines: a call to action.

To meet its population's health needs, the United States must have a coherent system to train and support primary care physicians. This goal can be achieved only though genuine collaboration between academic generalist disciplines. Academic general pediatrics, general internal medicine, and family medicine may be hampering this effort and their own futures by lack of collaboration. This essay addresses the necessity of collaboration among generalist physicians in research, medical education, clinical care, and advocacy. Academic generalists should collaborate by (1) making a clear decision to collaborate, (2) proactively discussing the flow of money, (3) rewarding collaboration, (4) initiating regular generalist meetings, (5) refusing to tolerate denigration of other generalist disciplines, (6) facilitating strategic planning for collaboration among generalist disciplines, and (7) learning from previous collaborative successes and failures. Collaboration among academic generalists will enhance opportunities for trainees, primary care research, and advocacy; conserve resources; and improve patient care.

Cooperative Behavior↗
PubMed1996

Developing generalists for Kentucky.

Since 1985, nearly half of the graduates of the University of Kentucky College of Medicine have chosen generalist careers, even though its students received almost no outpatient ambulatory training in primary care before 1990. This study determined the factors influencing the choice of generalist specialties in the absence of ambulatory training experience. A questionnaire was mailed to the 516 graduates of the classes of 1964 through 1989 who had entered a generalist specialty. A three-way ANOVA with one repeated measure was used to determine whether there were statistically significant differences in the responses of practitioners in the three generalist specialties (family practice, general internal medicine, or general pediatrics). Sufficiently complete responses were received from 187 graduates (116 family practitioners, 40 general pediatricians, and 31 general internists). Many of the physicians who had spent formative years in rural areas were practicing in rural communities. Many respondents had already decided upon a generalist career before entering medical school. Clerkships in internal medicine and pediatrics were an important influence, as was mentor role modeling. For pediatricians, an elective ambulatory care experience was also important. Educational experiences exert meaningful influences on students interested in a generalist career. Formal ambulatory care training experiences, while not critical for the selection of a generalist career, may heighten or confirm interest. Efforts that encourage students from rural communities to enter medical school appear to produce rural physicians.

Analysis of Variance↗
PubMed1997

Are the recommendations of the AAMC's task force on the generalist physician still valid?

A few years ago, most opinion leaders and workforce analysts believed that the number of generalist physicians in the United States was much too low. The AAMC responded to this concern by convening a task force to review the evidence bearing on the U.S. supply of generalist physicians and to make recommendations for action by the AAMC and its member institutions. In 1992, the task force called for at least half the graduates of U.S. allopathic medical schools to enter practice as generalists and for medical schools to design their educational programs to promote an affinity for generalism among their students. Since that time, however, research findings have suggested that the current size of the country's generalist physician workforce in relation to projected need may indeed be adequate. In light of these recent observations, the authors asked whether the task force's major recommendations remain valid. In this article, they state their reasons for thinking that it definitely does. After reviewing the recent research findings mentioned above, the authors show that simply to maintain the current size of the generalist physician workforce, a marked increase will be needed in the number of U.S. medical school graduates who choose to become generalists. In the aggregate, this amounts to roughly half the graduating classes of LCME-accredited medical schools, as called for by the AAMC in 1992. (The authors predict that international medical graduates will not make up a significant percentage of the country's generalist workforce, and that U.S. medical school graduates will be the predominant source of these physicians in the future.) Equally important, the new educational approaches being created by medical schools to embed generalism in their curricula are necessary to ensure that all graduates, regardless of their specialty choices, be well grounded in the principles and skills of "general physicians" so they can function well in the new health care system that is rapidly evolving.

Career Choice↗
PubMed1994

Preparing generalist physicians: the organizational and policy context.

A combination of financial, regulatory, and professional factors have led to a gradual but pronounced decline in generalist training and practice in the United States. This trend is likely to undergo dramatic reversal, however, as reflected by the diverse range of health care reform proposals incorporating incentives to promote generalist education and primary care practice. Considerable consensus has been reached by a number of professional organizations and public policy groups regarding the broad details of reform of generalist physician training, but key areas of controversy remain with important implications for academic medical centers. In addition, the generalist professional organizations, particularly those of family practice, general internal medicine, and general pediatrics, are being challenged to reconcile historic differences in the definitions and training of generalist competence. In this, the cell for "retraining subspecialists" with both offer an opportunity and entail a risk. Finally, academic medical centers will need new organizational structures that can combine the distinctive intellectual traditions and the expertise of the generalist medical disciplines to develop new approaches to the education and practice of primary care.

Academic Medical Centers↗
PubMed2002

Use of novel pollen species by specialist and generalist solitary bees (Hymenoptera: Megachilidae).

If trade-offs between flexibility to use a range of host species and efficiency on a limited set underlie the evolution of diet breadth, one resulting prediction is that specialists ought to be more restricted than generalists in their ability to use novel resource species. I used foraging tests and feeding trials to compare the ability of a generalist and a specialist solitary mason bee species to collect and develop on two pollen species that are not normally used in natural populations (novel pollens). Osmia lignaria (Hymenoptera: Megachilidae) is a generalist pollen feeder; O. californica, is more specialized. Adults of the specialist were more limited in use of novel hosts, but only in some contexts. Both bee species refused to collect one novel pollen. The specialist accepted a second novel pollen only when it was presented along with its normal pollen, whereas the generalist collected novel pollen whether presented alone or with normal pollen. Surprisingly, larvae of the specialist were more flexible than were generalists. The specialist grew well on mixtures of normal and novel pollen species, in some cases better than on its normal host alone. Larvae of the generalist grew more poorly on all diets containing novel pollens than on their normal host. Data on these two species of bees suggest that specialization by itself need not reduce flexibility on novel hosts. The findings also provide information about mechanisms of specialization in bees. Similar to some folivores, specific cues of the pollen host and the bee's interpretation of these contribute, along with foraging economics, to pollen choice by adults. The ability of the larvae to cope with specific components of one pollen species need not interfere with its ability to use others.

Adaptation, Physiological↗
PubMed1999

Knowledge, patterns of care, and outcomes of care for generalists and specialists.

OBJECTIVE: To critically evaluate the differences between generalist physicians and specialists in terms of knowledge, patterns of care, and clinical outcomes of care. METHODS: English-language articles (January 1981 to January 1998) were identified through a Medline search and examination of bibliographies of identified articles. Systematic evaluation of articles relevant to adult medicine that had a direct comparison between generalist physicians and specialists in terms of knowledge relative to widely accepted standards of care, patterns of care (including use of medications, ancillary services, procedures, and resource utilization), and outcomes of care was performed. MAIN RESULTS: In many survey studies, specialists were reported to be more knowledgeable about conditions encompassed within their specialty. In terms of overall practice patterns, specialists practicing in their area of expertise were more likely to use medications associated with improved survival and to comply with routine health maintenance screening guidelines; they used more resources including diagnostic tests, procedures, and longer hospital stays. In the limited number of studies examining the care of patients with acute myocardial infarction, acute nonhemorrhagic stroke, and asthma, specialists had superior outcomes compared with generalists. CONCLUSIONS: There is evidence in the literature suggesting differences between specialists and generalists in terms of knowledge, patterns of care, and clinical outcomes of care for a broad range of diseases. In published studies, specialists were generally more knowledgeable about their area of expertise and quicker to adopt new and effective treatments than generalists. More research is needed to examine whether these patterns of care translate into superior outcomes for patients. Further work is also needed to delineate the components of care for which generalists and specialists should be responsible, in order to provide the highest quality of care to patients while most effectively utilizing existing physician manpower.

Adult↗
PubMed2000

Specialist or generalist care? A study of the impact of a selective admitting policy for patients with cardiac failure.

CONTEXT: The debate on the respective roles of medical specialists and generalists has tended to portray them as alternatives, rather than seeking ways to build on the complementary skills of these professional groups. OBJECTIVE: We wished to evaluate the impact of a selective admitting policy that attempts to exploit the complementary strengths of specialists and generalists. DESIGN: Prospective cohort study of patients admitted to hospital with congestive heart failure. SETTING: Public hospital in New South Wales, Australia. PATIENTS: Subjects aged 60 years or more with congestive heart failure defined by the Framingham criteria (see Appendix). INTERVENTION: A selective admission policy which referred patients with identifiable single system disorders to the relevant subspecialist, while patients with multiple medical problems were admitted under a general physician. MAIN OUTCOME MEASURES: Length of hospital stay, survival, quality of life and satisfaction with care. RESULTS: Two-hundred and seventy-five patients with congestive heart failure were followed up from admission to 1 year after discharge from hospital. Of these, 102 were cared for by cardiologists and 154 by generalists. The patients under the generalists were older, had greater co-morbidity, but appeared to have less severe cardiac disease than those cared for by cardiologists. The use of cardiac drugs and investigations was similar in the two groups. The generalists' patients had a longer length of hospital stay, but the cardiologists' patients had a higher mortality during the early follow-up period. There were no differences in levels of satisfaction with care or in health-related quality of life between the two groups of patients. Multivariate analysis suggested that any differences in outcomes between the two groups of patients were due to the severity of underlying disease, and co-morbidity, rather than the quality of care that was provided by the physicians. CONCLUSIONS: It is possible to implement a hospital admission policy that selectively refers patients with congestive heart failure to specialists or generalists, according to the presence of co-morbid conditions, without adversely affecting the outcomes of care. Such a policy should represent optimum use of the complementary skills of these professional groups.

Aged↗
PubMed1999

Integrating early clinical experience curricula at two medical schools: lessons learned from the Robert Wood Johnson Foundation's Generalist Physician Initiative.

The University of Texas Medical Branch and Eastern Virginia Medical School have created community-based generalist clinical experiences early in the first two years of medical school as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative. This article describes these experiences and related curricula, outlining the common elements and differing approaches at the two institutions. It discusses the success of the new curriculum, presenting information from performance measures and surveys of students, clerkship directors, and faculty involved in the programs, and it describes further evaluative studies being planned. The authors discuss nine lessons learned and their conclusion that early clinical experience with generalist physicians is an important element of generalist curriculum reform. It improves student satisfaction with the first two years' experience and provides a structure for teaching patient-centered, integrated clinical medicine, which is important in the general professional education of all students. Whether or not the long-term goal of increasing students' interest in generalist careers is realized, incorporating early clinical experiences with generalists into a curriculum has positive effects on students, faculty, and the overall curriculum.

Curriculum↗
PubMed2001

The Interdisciplinary Generalist Curriculum Project at Eastern Virginia Medical School.

The proposed Interdisciplinary Generalist Curriculum (IGC) Project at Eastern Virginia Medical School (hereafter Eastern Virginia) intended to encourage students to select generalist disciplines by featuring generalist role models, focusing on patients' perspectives, teaching generalist skills early, providing care to indigent and other populations, and emphasizing students' personal and professional development. To do so, Eastern Virginia proposed that collaborative interdisciplinary groups of faculty plan and oversee the implementation of first- and second-year students' early clinical experiences in generalists' offices as integrated with new and revised first- and second-year courses, the coordination of generalist curricula longitudinally from year one through year four, and the provision of appropriate faculty development. With minor exceptions described, the project was implemented as proposed. The project did have desirable effects, both intended and unexpected. The curricular changes made in the project will remain.

Curriculum↗
PubMedDate not supplied

Generalist-subspecialist communication about children with chronic conditions: an analysis of physician focus groups.

OBJECTIVE: To describe barriers and facilitators to effective generalist-subspecialist communication in the care of children with chronic conditions. METHODS: We conducted 5 focus groups with 14 general pediatricians and 10 pediatric specialty providers to discuss factors that facilitate or obstruct effective communication. The specialty groups included 2 nurse practitioners; the rest were pediatricians from an academic medical center and the surrounding community. We performed a content analysis to generate groups of themes and classify them as barriers or facilitators, and we returned to the participants to solicit their feedback. RESULTS: We identified 201 themes in 6 domains: the method, content, and timing of communication; system factors; provider education; and interpersonal issues. Barriers to communication mostly involved the method of communication and system factors. Most facilitating themes promoted timely communication, understanding of the reasons for referral and the nature of the child's condition, or appropriate definition of generalist and specialist roles. Participants described numerous examples where communication had direct effects on patient outcomes. Generalists and specialists agreed on many issues, although specialists discussed the pros and cons of curbside consults at length whereas generalists emphasized the importance of their own education in the referral-consultation process. CONCLUSIONS: Efforts to improve communication between pediatric generalists and specialists in the care of children with chronic conditions should emphasize the importance of timely information transfer. The content of messages is important, but lack of receipt when needed is more of a problem. Improving generalist-subspecialist communication has great potential to improve the quality of care.

Child↗