Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Generalists”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 793 records · Page 44Linked to original sources
PubMed1993

The doctor is in.

The growing trend toward an overproduction of specialists and an underproduction of generalists (i.e., family physicians, general internists, and general pediatricians) in the United States has prompted many in medicine and academic medicine to endorse the goal that 50% of the United States's physician graduates should be generalists. The author discusses (1) the definition of the term generalist; (2) the number of generalists presently being produced (as estimated by three methods) and why the 50% goal is an informed and reasonable one; (3) changes needed in graduate medical education of the three main categories of generalist physicians; (4) changes needed in medical education; (5) changes needed in the practice environment; and (6) overall implementation strategies and the question of how much the federal government or some central authority should be involved. He concludes by reflecting that the 50% goal is worthwhile, although challenging, and that it is better to have a goal--even if it is not met--then to have no goal at all.

Education, Medical, Graduate↗
PubMed2002

Can medical school admission committee members predict which applicants will choose primary care careers?

PURPOSE: To determine the accuracy of admission committee members' predictions regarding which applicants are likely to become generalists, and to determine which applicant characteristics are used and should be used in making these predictions. METHOD: Thirteen characteristics of each applicant who entered medical school in 1990-1993 and graduated in 1994-1997 were obtained from their applications. Committee members reviewed these characteristics and assigned a probability of each applicant's choosing a generalist career. Just before their graduation, the students were surveyed to ascertain their career plans. The relationships between the characteristics and career predictions were analyzed using regression models. A secondary analysis examined the relationship between the students' stated career preferences at matriculation and career plans at graduation. RESULTS: The accuracy of the committee members' predictions was low. Predictions of generalist careers were significantly related to seven applicant characteristics: rural legal residence, gender (women), lower science grades, lower MCAT science scores, lower levels of parents' education, no reported research activity, and higher levels of community service. In contrast, the students' actual generalist career plans at graduation were significantly related only to gender (women) and higher levels of community service. In the secondary analysis, applicants' stated career preferences at matriculation were the strongest predictor of their having generalist career plans at graduation. CONCLUSIONS: Admission committee members often made inaccurate predictions about applicants' career plans. This may be because they based their judgments on applicants' characteristics that were not significantly related to the students' career plans at graduation.

Adult↗
PubMed2005

Internal medicine-pediatrics physicians: their care of children versus care of adults.

Purpose To determine how practicing physicians who graduated from internal medicine-pediatrics residency programs allocate their practice time and professional activities between adult and child patients, and to investigate whether there are predictors of the extent to which a particular physician's practice is more or less focused on one or the other of these patient groups. Method In 2003, the authors mailed a questionnaire to the 1,300 generalists and 472 subspecialists who, as of 2003, had completed internal medicine-pediatrics training since the inception of the program in 1980. Results The response rate was 73% for the generalists and 65% for the subspecialists. The vast majority of the generalist physicians stated that they provide care to all ages of patients. However, the proportion of care they provided to different age groups was not uniformly distributed, with more care provided to adults than children. Both generalist and subspecialist respondents were more likely to feel better prepared by their residency training to care for adults than for children. Those who felt less well-prepared to care for children were less likely to do so in their practices (odds ratio, 0.68; 95% confidence interval, 0.48-0.96). Fifty-four percent of the subspecialists pursued subspecialty training in internal medicine only, while 38% completed a combined internal medicine-pediatrics subspecialty program. These respondents, like the generalist respondents, also were more likely to focus clinical efforts on adults than children. Fewer than half (43%) provided any care to children zero to one year of age, while 54% provided at least some care to children aged two to 11 years. Conclusions Internal medicine-pediatrics physicians are more likely to spend a majority of their clinical care focused on adults and to perceive that they stay more current in the care of adults than of children. Potential reasons for this disparity may include training issues, greater reimbursement for the care of adults, perceptions of the impact on the medical market of the demographic shifts to older adults, and employment opportunities following training. These results also demonstrate the need for a more detailed and comprehensive assessment of the adequacy of pediatrics training in these programs.

Adolescent↗
PubMed1998

Health maintenance organization penetration and the practice location choices of new physicians: a study of large metropolitan areas in the United States.

OBJECTIVES: The rapid growth of health maintenance organizations is reshaping the practice opportunities available to physicians. The practice location decisions of new physicians provide a sensitive bellwether of these changes. This study assessed the effect of health maintenance organization penetration on practice location for physicians completing graduate medical education (GME). METHODS: Conditional logit regression analysis was used to determine the effect of health maintenance organization penetration on practice location, controlling for other market characteristics. Subjects were physicians who finished GME between 1989 and 1994 and who located in one of the 98 US metropolitan areas with more than 500,000 population. The outcome measure was the particular metropolitan area chosen by each new physician. RESULTS: Early in the study period, new generalists were significantly more likely to locate in metropolitan areas with high health maintenance organization penetration than in low penetration areas, whereas new specialists' practice location choices were not associated with health maintenance organization penetration. The likelihood of choosing a high penetration relative to a low penetration area declined with time, however, for both generalists and specialists. Consequently, by the end of the study period, health maintenance organization penetration had a weak but significant negative effect on practice location for generalists and a strong negative influence on practice location for specialists. CONCLUSIONS: New generalists who completed graduate medical education between 1989 and 1994 were more likely than new specialists to locate in market areas with high health maintenance organization penetration; however, the proportions of both generalists and specialists who chose high penetration areas decreased during the study period. This finding may reflect reduced practice opportunities in high penetration areas relative to low penetration areas as health maintenance organizations' systems for controlling utilization began to yield results. Alternatively, new physicians may have become more hesitant to accept available positions in high penetration areas.

Adult↗
PubMed2006

Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements.

BACKGROUND: The health care marketplace has changed substantially since the last assessment of demand for internal medicine physicians in 1996. METHODS: We reviewed internal medicine employment advertisements published in 4 major medical journals between 1996 and 2004. The number of positions, specialty, and other practice characteristics (e.g., location) were collected from each advertisement. RESULTS: Four thousand two hundred twenty-four advertisements posted 4,992 positions. Of these positions, jobs in the Northeast (31% of positions) or single specialty groups (36.8% of positions) were most common. The relative proportion of advertisements for nephrologists declined (P < .001), while the relative proportions of advertisements for critical care specialists (0.5% in 1996 to 1.7% in 2004, P = .004) and hospitalists (1.0% in 1996 to 12.1% in 2004, P < .001) increased. Advertisements for outpatient-based generalist positions (i.e., Primary Care and Internal Medicine) declined (-2.7% relative annual change, 95% confidence interval [95% CI] -4.1%, -1.2%) between 1996 and 2004, a decrease largely due to a substantial decline in advertisements noted between 1996 and 1998. However, over the entire time period, the combined proportion of advertisements for all generalists (hospitalists and outpatient-based generalists) did not change (0.5% relative annual change, 95% CI -0.8% to 2.0%). CONCLUSIONS: Since 1996, demand for the majority of medical subspecialties has remained constant while relative demand has decreased for primary care and increased for hospitalists and critical care. Increase in demand for generalist-trained hospitalists appears to have offset falling demand for outpatient generalists.

Advertising↗
PubMed1992

Entrance and exit of obstetrics providers in rural Alabama.

In Alabama between 1985 and 1989, a total of 94 physicians outside of the four largest cities in the state dropped the obstetrics portion of their practices or left practice in their communities altogether. During the same period 82 physicians entered obstetrics practice in this area. The study presented here used survey and archival data to compare practice characteristics of generalists and specialists in rural and town counties who made different decisions about providing obstetrics care. More generalists left and more specialists entered practice both in town and in rural counties. Rural counties lost more obstetrics providers because more generalists provided the obstetrics care in these areas. Across both specialty and county categories, physicians in group practice who accepted Medicaid and had local access to larger numbers of patients were more likely to remain or begin new obstetric practices. During this period, some obstetrics specialists moved into rural communities that had previously supported only generalist physicians. These findings suggest that the options for organizing successful obstetrics practices have narrowed, putting solo and generalist physicians who operate small-scale obstetrics practices at a disadvantage. These physicians also face competition from obstetrics specialists who are beginning to enter practice in the rural areas of the state. Designing policies that effectively improve geographic access to care requires a realistic understanding of the practice constraints faced by obstetrics providers. For example, as centralized specialist group practices serve residents from surrounding rural areas, programs that facilitate linkages, such as satellite clinics and use of mid-level practitioners, can be promoted.(ABSTRACT TRUNCATED AT 250 WORDS)

Alabama↗
PubMed2005

Temperature modulates taste responsiveness and stimulates gustatory neurons in the rat geniculate ganglion.

In humans, temperature influences taste intensity and quality perception, and thermal stimulation itself may elicit taste sensations. However, peripheral coding mechanisms of taste have generally been examined independently of the influence of temperature. In anesthetized rats, we characterized the single-cell responses of geniculate ganglion neurons to 0.5 M sucrose, 0.1 M NaCl, 0.01 M citric acid, and 0.02 M quinine hydrochloride at a steady, baseline temperature (adapted) of 10, 25, and 40 degrees C; gradual cooling and warming (1 degrees C/s change in water temperature >5 s) from an adapted tongue temperature of 25 degrees C; gradual cooling from an adapted temperature of 40 degrees C; and gradual warming from an adapted temperature of 10 degrees C. Hierarchical cluster analysis of the taste responses at 25 degrees C divided 50 neurons into two major categories of narrowly tuned (Sucrose-specialists, NaCl-specialists) and broadly tuned (NaCl-generalists(I), NaCl- generalists(II), Acid-generalists, and QHCl-generalists) groups. NaCl specialists were excited by cooling from 25 to 10 degrees C and inhibited by warming from 10 to 25 degrees C. Acid-generalists were excited by cooling from 40 to 25 degrees C but not from 25 to 10 degrees C. In general, the taste responses of broadly tuned neurons decreased systematically to all stimuli with decreasing adapted temperatures. The response selectivity of Sucrose-specialists for sucrose and NaCl-specialists for NaCl was unaffected by adapted temperature. However, Sucrose-specialists were unresponsive to sucrose at 10 degrees C, whereas NaCl-specialists responded equally to NaCl at all adapted temperatures. In conclusion, we have shown that temperature modulates taste responsiveness and is itself a stimulus for activation in specific types of peripheral gustatory neurons.

Action Potentials↗
PubMed2006

Nutrient regulation in relation to diet breadth: a comparison of Heliothis sister species and a hybrid.

We examined the nutritional correlates of diet breadth in insect herbivores by comparing patterns of diet selection, nutrient balancing, post-ingestive utilization and development in two sister species of caterpillar and a hybrid between them. One species, Heliothis virescens (HV) has a broad host range, feeding on plants in at least 14 families. The other, Heliothis subflexa (HS), is a specialist on plants in the genus Physalis (Solanaceae). Experiments using synthetic foods showed that when the caterpillars were allowed to mix their diet, the generalist self-selected a higher-protein diet whereas the specialist ate almost equal amounts of protein and carbohydrate, which accords with differences between the two species in the nutrient content of their natural diets. When confined to nutritionally imbalanced diets, the generalist showed a propensity to over-eat high protein:carbohydrate (P:C) diets to a greater degree than did the specialist and maintained higher rates of development. The generalist did not, however, over-eat low P:C diets to the same degree as the specialist. The hybrid selected a diet composition that was indistinguishable to that of its generalist father (HV), while its response to imbalanced diets was closely similar to that of the specialist mother (HS). The generalist converted ingested nutrient to growth with lower efficiency than did the specialist and the hybrid. Our findings imply that different behavioural and physiological traits linked to nutrient regulation are under genetic control and are explicable in terms of the different life-histories, feeding ecologies and presumed levels of nutritional heterogeneity in the environments of the two insects.

Animals↗
PubMed2002

When Patients Are Normal People: Strategies for Managing Dual Relationships.

A significant number of generalist physicians, particularly those in rural areas, often find themselves participating in the care of patients for whom the therapeutic relationship overlaps with another relationship (e.g., social or professional). Although psychiatrists and psychologists are typically advised to avoid such "dual relationships," no such prohibition exists for generalists. Little, if any, guidance exists to aid in the management of such dual relationships for the generalist who provides treatment for psychiatric conditions for his or her patients. The author, a generalist with experience in the treatment of mood disorders, describes potential challenges faced by the generalist who chooses to provide care for "dual relationship" patients and outlines strategies for successfully meeting these challenges.

Journal Article↗
PubMed1990

[The role of internal medicine in health services--time for retirement?].

Internal medicine is more than a hundred years old, even in Norway. Its intellectual fundament originates from nineteenth century medicine in Germany. Traditionally, these German physicians covered the entire field of medicine. However, due to lack of therapeutic remedies their main emphasis was on diagnosis and prognosis. During the last sixty years the tremendous increase in medical knowledge has led to a strong tendency towards organ specialization. The generalists in hospitals have met competition from general practitioners and specialists in geriatrics. At the same time their domain has steadily shrunk as the number of medical hospital beds has been reduced. Although not to the advantage of the patients, progress is wiping out the hospital generalists. Most (90%) hospital doctors are now organ specialists, although the majority of patients admitted to medical departments have diseases in more than one organ system. Therefore, generalists should be at least as equally appreciated as the organ specialists. To save the generalists the educational system must be changed. The two types of specialists should follow their own educational paths qualifying to separate and independent competence areas (general or organ-specific). Medical departments should be encouraged to maintain general sections in addition to the organ-specific sections. The generalist and the organ specialist should be professionally united in their efforts to develop internal medicine as a discipline.

Family Practice↗
PubMed1995

Should half of all medical school graduates enter primary care? Perceptions of faculty members at Jefferson Medical College.

PURPOSE: This study was undertaken to promote communication among faculty regarding the impact of a proposed goal that 50% of the graduates of Jefferson Medical College enter generalist careers. Since the opinions and attitudes of faculty regarding career decisions may directly or indirectly influence students, the authors investigated faculty's views of the optimal ratio of primary care to non-primary care physicians in the workforce and their perceptions of the effect on medical education, research, and health care delivery if the 50% goal were to be mandated. METHOD: A questionnaire was mailed in January 1994 to all 684 salaried faculty of Jefferson Medical College. Respondents' opinions about the optimal primary care to non-primary care ratio and their perceptions of the effects of implementing the 50% goal on 21 areas related to medical education, research, and health care delivery were examined using a Likert-type scale. Obstacles perceived by non-primary care physicians as preventing their practice of primary care were also among the outcome measures. RESULTS: A total of 275 completed questionnaires were received (40% response rate; 72 primary care physicians, 141 non-primary care physicians, and 62 non-physicians). The median and mode of an optimal primary care to non-primary care ratio were both 50/50. Faculty, in general, perceived that implementing the 50% goal would enhance public access to primary care, physician-patient relationships, utilization of non-physicians, and the career satisfaction of generalists. They predicted decreases in costs of care, freedom of career choice, funding, and interest in research. The primary care physicians perceived greater enhancements of the image of physicians, quality of care, and satisfaction of generalists and subspecialists than did the non-primary care physicians. Gender and age did not affect the perceptions. A lack of appropriate training was identified by 45% and a lack of interest by 28% of the non-primary care physicians as major obstacles to their practice of primary care medicine. CONCLUSION: The faculty members' positive and negative views of the proposed reform can provide useful information to the institution in understanding the potential impediments to increasing the numbers of generalist graduates. The generalists had significantly different views from the subspecialists about the impact of increasing the proportion of primary care physicians on health care delivery and research. In general the primary care physicians were more likely to view the proposed changes as beneficial than were the non-primary care physicians.

Attitude of Health Personnel↗
PubMed1996

Matching physician supply and requirements: testing policy recommendations.

Managed care has been growing and likely will increase market share. This movement will require fundamental alterations in the number and specialty distribution of physicians. Under current production, future supply does not appear well-matched with requirements. Although the adequacy of generalist supply is of concern, the oversupply of specialists is the overriding problem. Neither reducing the number of first-year residents nor increasing the generalist output alone would bring both generalist and specialist supply within requirement ranges. Combining an increase in generalist production to 50% with a reduction in first-year residents to 110% of the number of U.S. medical graduates would minimize the projected specialty surplus while maintaining generalist supply within the requirement range.

Education, Medical, Graduate↗
PubMed1997

Missed opportunities for prevention: smoking cessation counseling and the competing demands of practice.

BACKGROUND: Smoking cessation advice is an effective intervention for the control of tobacco use. The objective of this study was to assess and describe the rates of smoking status assessment and smoking cessation advice provided by physicians during ambulatory office visits with respect to physician specialty, type of visit, and number of problems addressed at the visit. METHODS: We used a cross-sectional survey of patient visits to the offices of nonfederally employed, office-based physicians participating in the 1992 National Ambulatory Medical Care Survey (n = 1558). RESULTS: Physicians reported knowing the smoking status of their patients in 66% of outpatient visits. The rate of assessment was similar for generalists and specialists. Cardiologists and generalists, except for pediatricians, showed discernible rates of smoking cessation advice (medians ranging from 14% to 50%), whereas obstetrician/gynecologists and other specialists had negligible rates. For tobacco-related visits, generalists and specialists had comparable rates of cessation advice to identified smokers. For non-tobacco-related visits, generalists had higher rates than specialists (22% vs 10%; P < .001). CONCLUSIONS: Although a substantial majority of smokers are reportedly identified by physicians during ambulatory visits, a large number of identified smokers are not receiving smoking cessation counseling. Patients seen by generalists are more likely to receive smoking cessation advice. Physicians appear to prioritize smoking cessation advice based on diagnosis at the time of the visit.

Adolescent↗
PubMed2005

General vs subspecialty pediatrics: factors leading to residents' career decisions over a 12-year period.

OBJECTIVES: To determine factors motivating residents' career choices and to examine changes in these priorities over the last 12 years. During the last decade, surveys of pediatric training programs have shown trends toward residents choosing careers in general pediatrics rather than in subspecialties. Most recently, there is evidence of a shift back toward subspecialty careers. DESIGN: We surveyed past and present residents at The Children's Hospital of Philadelphia, Philadelphia, Pa, (training completion dates, 1991-2002) via an anonymous written questionnaire. RESULTS: The sample comprised 238 residents (mean +/- SD age, 30 +/- 3 years; 59% female, 41% male; 47% subspecialists, 53% generalists). Among the group as a whole, subject matter, role models, lifestyle issues, and teaching were the most important determinants for career choices. Less important were national trends, job openings, and research. When subspecialists and generalists were compared, both groups found subject matter to be their highest priority. Among residents interested in subspecialties, teaching, research, and technical skills were significant (P<.001), compared with generalists, who considered lifestyle and personal/financial issues more important (P<.001). Lifestyle issues were also more important to female residents, those 30 years of age or younger, and those completing training recently (P<.05). CONCLUSIONS: Career decisions for pediatric residents today are motivated by complex factors. For those choosing generalist careers, lifestyle and personal/financial considerations predominate, while teaching, research, and technical skills are key factors for subspecialists. Over the last decade, lifestyle issues have become a more dominant factor, particularly for women entering the pediatric workforce.

Adult↗
PubMed1995

Career choice in one general pediatric Title VII--supported residency.

The concern that there are too few generalist physicians and too many specialists is part of the ongoing health care debate. Medical educators have been challenged at the graduate and undergraduate levels to educate more generalists. While some question the actual effect of medical education on the choice of a generalist career, others strongly express the view that a generalist curriculum influences graduates to pursue a career in primary care. Residency training programs are largely based in hospitals, and pediatric practice is largely community based. The terms educational malpractice, educational mismatch, and, most recently, educational dysjunction have been used to describe the difference between the educational and practice experience.

Boston↗
PubMed2005

Use of physician services in a population-based cohort of patients with polymyalgia rheumatica over the course of their disease.

OBJECTIVE: To describe the use of generalist and rheumatologist services in a population-based cohort of patients with polymyalgia rheumatica (PMR) and to identify predictors of rheumatology care. METHODS: We identified all incident cases of PMR among residents of Olmsted County, Minnesota between 1970 and 1999. Patients were followed for a maximum of 5 years after their incidence date. Logistic regression and zero-inflated Poisson regression models were used to assess the association between rheumatology care and age, sex, giant cell arteritis (GCA), PMR relapses, corticosteroid complications, comorbidity, and various laboratory findings, adjusting for the total number of visits. RESULTS: Of the 364 incident cases of PMR eligible for this analysis, 67% were women and the mean age at incidence was 73 years. Over a mean followup of 4.1 years, individuals in this cohort utilized a total of 5,108 physician office visits and 2,015 telephone calls. The mean number of generalist and rheumatologist visits per person-years of follow-up during the first year of PMR was 7.02 and 2.15, respectively. Thereafter, there was a steady decline in both generalist and rheumatologist visits. One hundred forty-four (40%) patients had no rheumatologist visits and 102 (28%) had only 1 rheumatologist visit, mostly for diagnostic confirmation. Men and patients with several comorbid conditions were significantly more likely to be seen by rheumatologists (P < 0.001). However, once referred, women, older patients, and those with GCA, PMR relapses, and corticosteroid complications had significantly more rheumatologist visits (P < 0.001). CONCLUSION: The use of physician services in PMR is considerable. Generalists provide the large majority of care. Rheumatologist involvement is generally limited to diagnostic confirmation and management of complications. The relative paucity of rheumatology care following the period of diagnosis may represent an opportunity for improving the care of patients with PMR.

Aged↗
PubMed1998

Unstable angina: specialty-related disparities in implementation of practice guidelines.

BACKGROUND: The agency for Health Care Policy and Research (AHCPR) has published practice guidelines to improve the quality of care patients with unstable angina. Prior to publication, studies demonstrated that when compared with cardiologists, internists were less likely to use effective pharmacologic therapies or revascularization in patients with unstable angina. HYPOTHESIS: The study was undertaken to determine whether the AHCPR guideline publication abolished specialty-related disparities in care. METHODS: We performed a chart review of consecutive patients hospitalized at a university-affiliated institution with an admission diagnosis of chest pain in the absence of myocardial infarction and a noncardiac etiology. Treatment and diagnostic cardiac testing were compared between risk-stratified patients cared for by a generalist (n = 125) and those whose care was guided by a cardiologist (n = 211). RESULTS: In those with low-risk unstable angina, generalists were less likely to prescribe recommended aspirin (71 vs. 88%, p < 0.01) and beta blockers (9 vs. 37%, p < 0.001), and heparin (20 vs. 49%, p < 0.001), and to perform a recommended diagnostic stress test or cardiac catheterization (28 vs. 60%, p < 0.001). In those with at least intermediate risk, generalists were less likely to prescribe beta blockers (19 vs. 52%, p < 0.001), heparin (19 vs. 66%, p < 0.001), and nitrates (77 vs. 96%, p < 0.001), and to refer for diagnostic testing (19 vs. 65%, p < 0.001). Generalists' care was associated with significantly lower hospital charges. CONCLUSIONS: AHCPR guidelines for the evaluation and treatment of unstable angina are implemented more effectively, but not uniformly, by cardiologists at our institution. Further studies are necessary to evaluate the barriers to implementation of the AHCPR guidelines.

Aged↗
PubMed2005

[Costs of ambulatory care for RA patients in Germany].

BACKGROUND: In 2000, the Regional Cooperative Center for Rheumatic Conditions in Hannover, Germany, initiated a project to introduce and evaluate a case-based clinical quality management system to enhance the quality of care for patients with rheumatoid arthritis. Building on that, it was possible to combine all resource uses, as paid by the sickness funds, including those in ambulatory care. METHODS: The purpose of this study was to reach average "per-visit prices" for single physician visits, not only for rheumatologists, but also for other specialists as well as generalists. Those visits all had to be connected to the rheumatic condition of the patients. All ambulatory care visits for 1 year (2001) were evaluated. RESULTS: Due to the high number of physician visits of the 338 patients with clinically assured rheumatoid arthritis included in the study (rheumatologist visits 4,488, generalist visits 3,901), statistically significant subgroups could be built. The average costs per visit associated with rheumatoid arthritis are: rheumatologist euro 22.71; generalist euro 8.02; as well as other specialties ranging from euro 5.81 to euro 19.48. The low price for generalists care is due to the selection of the cohort, as all patients are under constant specialist care. The prices were further broken down to certain subgroups of care. CONCLUSION: The prices are calculated under the premises that no budgetary constraints apply to ambulatory care. This is not the reality in Germany. Hence, looking at the average frequency of rheumatologist visits in this cohort (13.2/year), the conclusion has to be that not all rheumatologic ambulatory care is being covered by the reimbursement system within the Statutory Health Insurance in Germany.

Adult↗