PRIME: preparing first-year medical students for an intensive clinical experience. The Generalist Coordinating Council.
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Education, Medical, Undergraduate↗
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Where have the generalists gone?
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Australia↗
Cochlear implantation. Practical information for the generalist.
The diagnosis and investigation of a patient with bilateral, severe-to-profound sensorineural hearing loss is presented. The steps toward cochlear implantation, including tests of audition, balance, radiographic imaging, and the pre- and postrehabilitation period, are reviewed. The two major cochlear implants available today, and future developments within the cochlear implant, are presented.
Audiometry↗
[Is it necessary to train generalists in urgent pediatric care? Experience with an inter-university curriculum of urgent care in pediatrics in the Rhone-Alps region].
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Child↗
Gustatory neuron types in rat geniculate ganglion.
We used extracellular single-cell recording procedures to characterize the chemical and thermal sensitivity of the rat geniculate ganglion to lingual stimulation, and to examine the effects of specific ion transport antagonists on salt transduction mechanisms. Hierarchical cluster analysis of the responses from 73 single neurons to 3 salts (0.075 and 0.3 M NaCl, KCl, and NH(4) Cl), 0.5 M sucrose, 0.01 M HCl, and 0.02 M quinine HCl (QHCl) indicated 3 main groups that responded best to either sucrose, HCl, or NaCl. Eight narrowly tuned neurons were deemed sucrose-specialists and 33 broadly tuned neurons as HCl-generalists. The NaCl group contained three identifiable subclusters: 18 NaCl-specialists, 11 NaCl-generalists, and 3 QHCl-generalists. Sucrose- and NaCl-specialists responded specifically to sucrose and NaCl, respectively. All generalist neurons responded to salt, acid, and alkaloid stimuli to varying degree and order depending on neuron type. Response order was NaCl > HCl = QHCl > sucrose in NaCl-generalists, HCl > NaCl > QHCl > sucrose in HCl-generalists, and QHCl = NaCl = HCl > sucrose in QHCl-generalists. NaCl-specialists responded robustly to low and high NaCl concentrations, but weakly, if at all, to high KCl and NH(4) Cl concentrations after prolonged stimulation. HCl-generalist neurons responded to all three salts, but at twice the rate to NH(4) Cl than to NaCl and KCl. NaCl- and QHCl-generalists responded equally to the three salts. Amiloride and 5-(N,N-dimethyl)-amiloride (DMA), antagonists of Na(+) channels and Na(+)/H(+) exchangers, respectively, inhibited the responses to 0.075 M NaCl only in NaCl-specialist neurons. The K(+) channel antagonist, 4-aminopyridine (4-AP), was without a suppressive effect on salt responses, but, when applied alone in solution, it evoked a response in many HCl-generalists and one QHCl-generalist neuron so tested. Of the 39 neurons tested for their sensitivity to temperature, 23 responded to cooling and chemical stimulation, and 20 of these neurons were HCl-generalists. Moreover, the responses to the four standard stimuli were reduced progressively at lower temperatures in HCl- and QHCl-generalist neurons, but not in NaCl-specialists. Thus sodium channels and Na(+)/H(+) exchangers appear to be expressed exclusively on the membranes of receptor cells that synapse with NaCl-specialist neurons. In addition, cooling sensitivity and taste-temperature interactions appear to be prominent features of broadly tuned neuron groups, particularly HCl-generalists. Taken all together, it appears that lingual taste cells make specific connections with afferent fibers that allow gustatory stimuli to be parceled into different input pathways. In general, these neurons are organized physiologically into specialist and generalist types. The sucrose- and NaCl-specialists alone can provide sufficient information to distinguish sucrose and NaCl from other stimuli, respectively.
Animals↗
What influences career choices among graduates of a primary care training program?
OBJECTIVE: To identify factors that influence primary care residents to become generalists or specialists. DESIGN: Structured survey and interview. SETTING: A large university-based, internal medicine residency program in primary care. PARTICIPANTS: Of 92 residency graduates who completed training between 1979 and 1993, 88 (96%) participated. MAIN RESULTS: Although 82% of the participating graduates reported themselves very committed to primary care at the beginning of residency, only 68% pursued generalist careers. Factors influencing career choice that were more important to generalists than specialists included breadth of knowledge used in primary care practice (p = .04), breadth of clinical problems in practice (p = .001), and opportunity for continuity of care (p = .01). Although salary was rated "not important," 50% of generalists and specialists advocated increased salaries for generalists as a way to increase interest in primary care. Other promoting factors included mentors, increased prestige for generalists, community-based training, lifestyle changes, and decreased paperwork. Seventy-three percent of participants felt it was easier to be a specialist than a generalist. CONCLUSIONS: A substantial minority of primary care residents pursue specialty careers. To produce more generalists, graduates recommend addressing income inequities, providing generalist role models, increasing community-based teaching, and increasing prestige for generalists.
Career Choice↗
Specialty training and specialization among physicians who treat HIV/AIDS in the United States.
OBJECTIVE: To assess the association of specialty training and experience in the care of HIV disease with HIV-specific knowledge, referral patterns, and HIV-related education activities. DESIGN: Cross-sectional survey. SETTING: The United States. PARTICIPANTS: Physicians caring for patients in the HIV Costs and Service Utilization Study, a study of a probability sample of HIV-infected individuals in the United States. MEASUREMENTS AND MAIN RESULTS: Measures included physicians' reports of specialty training and HIV caseload, scores on an HIV-specific knowledge test, referral patterns, and attendance rates at HIV-related educational activities. Approximately 72% (379) of the eligible physicians completed a survey. Of these, 152 (40%) had infectious disease (ID) training, and 213 (56%) were generalists; 4% of ID-trained physicians and 37% of generalist physicians did not consider themselves HIV experts. The median current caseloads were 150 and 200 patients for ID experts and generalist experts, respectively. In contrast, the median caseload for non-expert generalists was 5. Mean scores on the knowledge scale were similar for ID and generalist experts (9.0 items correct out of 11 vs 8.5; P=not significant), but lower for generalist non-experts (6.5 items correct; P <.01). Experts had attended more local and national HIV meetings than non-experts (9.3 vs 2.7; P <.01, and 2.3 vs.40; P <.01, respectively) in the past year. Fewer ID experts ever referred than generalist experts (13.0% vs 27.3%; P=.01). In multivariable models that included specialty training and caseload, physicians with caseloads of 20 to 49 and >50 were more likely to have a high knowledge score (defined as 80% or more correct, odds ratio [OR], 2.8; P=.04 and OR, 5.7; P <.001, respectively), and the effect of specialty was attenuated (OR, 2.7; P=.02 decreased from OR, 7.8; P <.001 in a model without caseload). In the models predicting referral practices, both experience (OR,.25; P <.01 and OR,.17; P <.01 for caseloads of 20 to 49 and >50, respectively) and specialty (OR,.19; P <.01 and OR,.09; P <.01 for generalist and ID experts, respectively) were significant. CONCLUSIONS: In a national sample of physicians, HIV-specific knowledge was more strongly associated with HIV caseload than with specialty training. In addition, although referral practices were related to both experience and specialty, generalist experts and ID physicians reported similar behaviors. This suggests that generalist physicians, through clinical experience and self-education, can develop specialized knowledge in HIV care.
Acquired Immunodeficiency Syndrome↗
Cannibalism and intraguild predation among phytoseiid mites: are aggressiveness and prey preference related to diet specialization?
We tested whether specialist and generalist phytoseiid mites differ in aggressiveness and prey choice in cannibalism and intraguild predation. Specialists tested were Galendromus occidentalis, Neoseiulus longispinosus, Phytoseiulus persimilis, and P. macropilis; generalists tested were Amblyseius andersoni, Euseius finlandicus, E. hibisci, Kampimodromus aberrans, Neoseiulus barkeri, N. californicus, N. cucumeris, NM fallacis, and Typhlodromus pyri. Aggressiveness of cannibalistic females against larvae was not related to diet specialization except that highly aggressive species were exclusively generalists. Seldom to moderately cannibalizing species occurred in both generalist and specialist phytoseiids. In contrast to aggressiveness in cannibalism, generalists and specialists differed in aggressiveness in intraguild predation. Adult females of specialists were only slightly aggressive against heterospecific larvae, whereas adult females of all generalists except T. pyri were highly aggressive. Adult females of generalists were able to discriminate between con- and heterospecific larvae and preferentially consumed the latter when given a choice. Adult females of specialists except G. occidentalis showed no preference when given a choice between con- and heterospecific larvae. We conclude that aggressiveness in intraguild predation, species recognition and subsequent preferential consumption of heterospecifics when given a choice is common in generalist but not specialist phytoseiids. We discuss the evolutionary pathways that might have led to the difference between specialists and generalists in species discrimination.
Aggression↗
Dietary specialization influences the efficacy of larval tortoise beetle shield defenses.
Plant chemical defenses and escape from natural enemies have been postulated to select for dietary specialization in herbivorous insects. In field and laboratory bioassays, we evaluated the effectiveness of intact and chemically modified larval shield defenses of the generalist Chelymorpha alternans and the specialists Acromis sparsa and Stolas plagiata (Chrysomelidae: Cassidinae) against three natural predators, using larvae reared on two morning glory (Convolvulaceae) species. We assessed whether: (1) specialists were better defended than generalists when both were fed and assayed on the same plant; (2) larval shield defenses were chemical, physical, or both; and (3) specialists exploit chemistry better than generalists. Live specialist larvae survived at higher rates than did generalists in predator bioassays with the bug Montina nigripes (Reduviidae), but there were no differences among groups against two species of Azteca ants (Hymenoptera: Dolichoderinae). Solvent leaching by H(2)O or MeOH significantly reduced shield efficacy for all species compared to larvae with intact shields. In contrast, freshly killed specialist larvae exhibited significantly lower capture rates and frequencies than the generalists. Although solvent leaching significantly reduced overall shield efficacy for freshly killed larvae of all species, the pattern of leaching effects differed between specialists and generalists, with H(2)O-leaching having a greater impact on the specialists. The overall vulnerability of the generalists appears due to lower chemical protection, which is ameliorated by increased escape behaviors, suggesting a selective trade-off between these defensive components. These experiments indicate that shield defenses are essential for larval survival and that specialists are superior at exploiting plant compounds residing in the aqueous fraction. Our results support the hypothesis that diet-specialized herbivorous insects have more effective defenses than generalists when both feed on the same plant due to the differential ability to exploit defensive precursors obtained from the host. The evolution of dietary specialization may therefore confer the advantage of enhanced enemy-free space.
Adaptation, Biological↗
Benzodiazepines prescription in Dakar: a study about prescribing habits and knowledge in general practitioners, neurologists and psychiatrists.
Benzodiazepines are relatively well-tolerated medicines but can induce serious problems of addiction and that is why their use is regulated. However, in developing countries like Senegal, these products are used without clear indications on their prescription, their dispensation or their use. This work focuses on the prescription of these medicines with a view to make recommendations for their rational use. Benzodiazepine prescription was studied with psychiatrists or neurologists and generalists in 2003. Specialist doctors work in two Dakar university hospitals and generalists in the 11 health centres in Dakar. We did a survey by direct interview with 29 of 35 specialists and 23 of 25 generalists. All doctors were interviewed in their office. The questionnaire focused on benzodiazepine indications, their pharmacological properties, benzodiazepines prescribed in first intention against a given disease and the level of training in benzodiazepines by doctors. Comparisons between specialists and generalists were made by chi-square test. Benzodiazepines were essentially used for anxiety, insomnia and epilepsy. With these diseases, the most benzodiazepines prescribed are prazepam against anxiety and insomnia and diazepam against epilepsy. About 10% of doctors do not know that there is a limitation for the period of benzodiazepine use. The principal reasons of drugs choice are knowledge of the drugs, habit and low side effects of drugs. All generalists (100%) said that their training on benzodiazepines is poor vs. 62.1% of specialists, and doctors suggest seminars, journals adhesions and conferences to complete their training in this field. There are not many differences between specialists and generalists except the fact that specialists prefer prazepam in first intention in the insomnia treatment where generalists choose bromazepam. In addition, our survey showed that specialists' training in benzodiazepines is better than that of generalists. Overall, benzodiazepine prescription poses problems particularly in training, and national authorities must take urgent measures for rational use of these drugs.
Anxiety↗
Nutrient balancing in grasshoppers: behavioural and physiological correlates of dietary breadth.
We examined correlates of nutrient balancing with dietary range by comparing diet selection and ingestive, post-ingestive and performance-related responses to macronutrient imbalance in two species of grasshopper. One of the two species, Locusta migratoria (the African migratory locust), is a specialist grass-feeder, while the other, Schistocerca gregaria (the desert locust), is a generalist herbivore that includes both grasses and forbs in its diet. In ad libitum conditions, both species composed a balanced intake of the two macronutrients protein and carbohydrate from nutritionally complementary synthetic foods, but the composition of the selected diet differed, with the generalist selecting more protein, but not carbohydrate, than the grass-specialist. The grass-specialist, by contrast, retained ingested nitrogen more efficiently on the ad libitum diets. When confined to nutritionally imbalanced foods, both species regulated ingestion in such a way as to mitigate excesses as well as deficits of the two nutrients. The responses were, however, distinct in the two species, with the generalist feeder ingesting greater excesses of protein than the specialist. The species also differed in their post-ingestive responses to ingested excesses of nutrient, with the generalist but not the specialist using protein-derived carbon as an energy source when fed carbohydrate-deficient foods. The generalist also retained a higher level of body protein when confined to protein-deficient diets. The data suggested one functional reason why the generalist species selected a diet with higher protein content in the ad libitum treatment because, when confined to the nutritionally imbalanced foods, development rate peaked on higher protein foods for the generalist compared with the specialist. Many aspects of these data agree with the prediction that generalist-feeding animals should show greater behavioural and physiological flexibility in their responses to nutrient imbalance than do specialists.
Animal Nutritional Physiological Phenomena↗
Do clinical nurse specialists in palliative care de-skill or empower general ward nurses?
This article reports on a small-scale exploratory study looking into the relationships between specialist nurses and general nurses in acute palliative care, to establish mutual role expectations and conditions under which generalists exhibit empowered or de-skilled behaviour. The main aims were to investigate understandings of role expectation and to establish the conditions under which generalists exhibited empowered or de-skilled behaviour. Semi-structured interviews, based on a patient vignette, were conducted with eight general nurses and two specialist nurses in one UK NHS trust. It was found that generalists valued specialists' clinical knowledge and skills, especially their communication skills. However, generalists demonstrated little insight into the work methods or full job remit, particularly the educational role, of specialists. There was a common understanding of the generalist's role by both generalists and specialists. Generalists shared anxieties about palliative care. De-skilling was not reported, but generalists acknowledge 'handing over' care and a disinclination to develop challenging clinical skills. Empowerment was not found to be associated with clinical grade, but with motivation to learn about palliative care. Further research is required to verify these preliminary findings.
Interprofessional Relations↗
Physician specialization and the quality of care for human immunodeficiency virus infection.
BACKGROUND: There is debate over the types of physicians who should treat patients with complex chronic medical conditions such as human immunodeficiency virus (HIV) infection. We sought to assess the relationship between specialty training and expertise and the quality of care delivered to patients with HIV infection. METHODS: We selected random samples of HIV-infected patients receiving care at 64 Ryan White CARE (Comprehensive AIDS Resources Emergency) Act-funded clinics throughout the country and their primary HIV physicians for an observational cohort study in which quality-of-care measures were assessed by medical record review. RESULTS: We studied 5247 patients linked to 177 physicians who responded to a survey. Fifty-eight percent of the physicians were general medicine physicians ("generalists") and 42% were infectious diseases specialists. Sixty-three percent of the generalists (37% overall) considered themselves expert in HIV care. In hierarchical logistic regression models that controlled for patient characteristics, infectious diseases physicians and expert generalists had similar performance. In contrast, nonexpert generalists delivered lower quality care. More than 80% of the appropriate patients being cared for by infectious diseases physicians and expert generalists were receiving highly active antiretroviral therapy, compared with 73% of appropriate patients of nonexpert generalists (P<.001). Physicians with fewer than 20 patients with active HIV had fewer appropriate patients on highly active antiretroviral therapy (73% vs 82% of physicians with >/=20 such patients, P = .04) and saw patients less frequently. CONCLUSION: These findings extend previous work by examining a range of quality-of-care measures and suggest that generalists with appropriate experience and expertise in HIV care can provide high-quality care to patients with this complex chronic illness.
Adult↗
Elimination of plant toxins by herbivorous woodrats: revisiting an explanation for dietary specialization in mammalian herbivores.
Constraints on rates of detoxification and elimination of plant toxins are thought to be responsible for limiting dietary specialization in mammalian herbivores. This hypothesis, known as the detoxification limitations hypothesis, suggests that most mammalian herbivores are generalists to avoid overdosing on toxins from a single plant species. The hypothesis also predicts that the few mammalian specialists that exist should have adaptations for rapid detoxification and elimination of plant secondary compounds. We took a pharmacological approach to test whether specialists eliminate toxins from the bloodstream faster than generalists. We compared elimination rate and total exposure of alpha-pinene in closely related dietary specialist and generalist woodrats, Neotoma stephensi and N. albigula, respectively. Animals were orally gavaged with alpha-pinene, a plant secondary compound present in the natural diets of both woodrat species. We collected venous blood at 3, 6, 10, 15, and 20 min post-ingestion of alpha-pinene. Blood was analyzed for alpha-pinene concentration using gas chromatography. We found that specialist and generalist woodrats did not differ in elimination rates of alpha-pinene. However, specialists had lower exposure levels of alpha-pinene than generalists due to lower initial delivery of alpha-pinene to the general circulation. The levels of alpha-pinene detected in the bloodstream of specialists were 4.7-5.3x lower over all time intervals than generalists. Thus, specialists encounter a functionally lower dose of toxin than generalists. We suggest that the lower exposure level of specialist woodrats may be due to mechanisms in the gut that decrease toxin absorption. Regardless of mechanism, lower exposure to plant toxins may allow specialists to forage on diets with high toxin concentrations thereby facilitating dietary specialization.
Absorption↗
Effects of specialization on genetic differentiation in sister species of bark beetles.
We investigated the relative importance of resource use and geography on genetic differentiation in the sister-species pair of generalist and specialist bark beetles: Dendroctonus ponderosae and D. jeffreyi (Coleoptera: Scolytidae). In two regions, where the distributions of these species overlap, we collected specimens of the generalist from multiple host species and specimens of the specialist from its single host species. Using allozyme techniques, we uncovered genetic differentiation between generalist populations on different host species in the same region (one locus in each region). However, a much stronger pattern of differentiation was found between specialist populations in the two distantly separated regions (three loci). With mtDNA, we found no significant differentiation between regions in the specialist, or among host species in the generalist, although there was some differentiation between regions in the generalist (AMOVA, P < 0.05). Overall, the generalist populations maintained approximately 10 times the genetic variation in mtDNA as the specialist populations, which suggests that the specialist either has generally smaller population sizes than the generalist, or has experienced a historical population bottleneck.
Alleles↗
Relationship between primary care practices in medical school admission and the matriculation of underrepresented-minority and female applicants.
PURPOSE: To determine whether primary care-oriented (generalist) admission practices at U.S. medical schools address physician workforce diversity issues by resulting in the admission of more members of underrepresented-minority populations or more women. METHOD: The authors performed cross-sectional, secondary analyses of databases from the Association of American Medical Colleges (AAMC). The independent variables were four generalist admission practices: generalist admission committee chair, greater representation of generalists on admission committee, offering preferential admission to likely generalists, and having a premedical recruitment activity targeting likely generalists. The control variable was public/private school ownership. The dependent variables were the mean ages of the matriculating classes and the proportions of students at each school who were African American, (total) underrepresented minorities, women, and married. RESULTS: Ninety-five percent of medical schools completed the AAMC's Survey of Generalist Physician Initiatives in either 1993 and 1994; 94% of matriculants replied to the AAMC's 1994 Matriculating Student Questionnaire. In multivariable analyses, no admission practice was associated with percentages of African Americans, total underrepresented minorities, or women. CONCLUSIONS: Schools with primary care-oriented admission practices did not admit greater percentages of underrepresented-minority students or women. Additional efforts may be required to attract and admit minority and female applicants.
Black or African American↗
Effect of physician specialty on outcomes in diabetic ketoacidosis.
OBJECTIVE: More than 100,000 people are hospitalized annually in the U.S. with diabetic ketoacidosis (DKA). Outcome differences have not been examined for these patients based on whether their primary care provider is a generalist or a diabetes specialist. The objective of this study was to investigate hospital charges and hospital length of stay (LOS) for patients with DKA according to the specialty of their primary care provider. RESEARCH DESIGN AND METHODS: We investigated all patients with a primary diagnosis of DKA during a 3.5-year period (n = 260) in a large urban teaching hospital. Hospital charges and LOS were studied regarding the specialty of the primary care provider. Demographic factors, severity of illness, laboratory data, and readmission rates were compared. RESULTS: Patients cared for by generalists and endocrinologists had a similar case mix and severity of DKA. The age-adjusted mean LOS for patients of generalists was 4.9 days (95% CI 4.5-5.4), and the mean LOS for patients of endocrinologists was 3.3 days (2.6-4.2) (P < 0.0043). Mean hospital charges differed (P < 0.0001) with an age- and sex-adjusted mean for patients of endocrinologists of $5,463 ($4,179-7,141) and a mean for patients of generalists of $10,109 ($9,151-11,166). The additional charges incurred by generalists were due in part to patients undergoing more procedures. No differences in diabetes-related complications occurred during admission, but the endocrinologist-treated group had a lower readmission rate for DKA during the study period than the generalist-treated group (2 vs. 6%, respectively) (P = 0.03). CONCLUSIONS: Endocrinologists provide more cost-effective care than generalists do when serving as primary care providers for patients hospitalized with DKA.
Adolescent↗
Influence of new evidence on prescription patterns.
BACKGROUND: It is currently accepted that no drug can enter clinical practice without proved efficacy in clinical trials. Improving patient care requires that the results of clinical evaluation be translated into practice. Results of studies are conflicting, but there is support that well-executed, clinically relevant randomized trials published in highly visible clinical journals can have an effect on patterns of medical practice. METHODS: We evaluated the potential impact of the publication in a leading journal of different drug studies (metformin, alendronate, terazosin, and finasteride) on the prescription behavior of generalists and specialists. Using a health maintenance organization (HMO) prescription drug database, we analyzed the incidence of new prescriptions written by generalists and specialists from a university-affiliated HMO before and after the publication date of the studies. RESULTS: The proportions of new prescriptions changed between a 6-month period before publication and a 6-month period after publication. The rate for alendronate increased from 31.7% to 43.2% of all prescriptions for specialists (P = NS) and from 8.8% to 38.9% for generalists (P < .01). The rate for metformin increased from 26.7% to 46.4% for specialists (P = .04) and from 7.9% to 24.2% for generalists (P < .01). The rate for alpha1-blockers decreased from 48.7% to 38.9% (P = NS) for specialists and increased from 20.7% to 60% for generalists (P < .01). The rate for finasteride decreased from 40.9% to 19.64% for specialists (P < .01) and from 22.11% to 11.3% for generalists (P = .01). CONCLUSIONS: The change in the prescription patterns of all physicians showed a clear temporal association with the publication of new evidence. The greater change observed for generalists could be explained by their lower baseline use of the drugs and a more conservative behavior that might defer the adoption of new treatments until they are supported by strong evidence published in major journals.
Adrenergic alpha-Antagonists↗