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PubMed1999

Performance of third-year primary-care-track students in an integrated curriculum at Case Western Reserve University.

In 1994, Case Western Reserve University School of Medicine established a Primary Care Track (PCT) with an integrated curriculum as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative. This study compared the performance of the first cohort of students to participate in the PCT third year with that of their classmates and determined student attitudes toward their experiences. The performances of 24 PCT and 81 traditional students on the Medical School Admissions Test (MCAT) and the United States Medical Licensure Examination (USMLE) Step 1 and 2 were compared using analysis of variance. Grades on the six core clerkships were compared using chi-square analysis. Performances of the PCT students and a subset of traditional students on the generalist school's objective structured clinical exam (OSCE) were compared using multivariate analysis. The students reported their perceptions on a questionnaire. The traditional students had significantly higher scores on the physical science section of the MCAT and on the USMLE Step 1, but at the end of year three, their USMLE Step 2 scores did not differ. Grade distributions in the core clerkships did not differ, except in psychiatry, where the PCT students received honors significantly more often. The PCT students had a lower mean score on the internal medicine National Board of Medicine Examiners shelf exam but performed better on the generalist OSCE exam. A majority of PCT students reported that they would choose the integrated third year again and recommend it to others.

Adult↗
PubMed2001

Surveying graduates of one school to determine regional workforce demand.

PURPOSE: To study the demand for physician graduates from one school in one region of the country. The use of demand as a measure of potential regional variation should be of interest to medical educators and policymakers. METHOD: All residency graduates of the University of Washington School of Medicine between 1975 and 1995 (n = 3,824) were surveyed about their ability to gain employment in a timely manner and whether they were recruiting physicians for their practices. RESULTS: The response rate was 50.29%. A non-responder survey was done using a subsample (n = 200), with a 28% return. Over 95% of the graduates had found employment in their desired specialties and locations within two years of finishing their residencies. This was the same for graduates over all years. Approximately 30% of all practices of respondents within the Northwest region were recruiting for new physicians (26% of specialty practices and 34% of generalist practices were recruiting). There was no difference between recruitment in the urban and rural practices or between respondents to the initial survey and those responding to the follow up. CONCLUSIONS: Despite a significant oversupply of specialist physicians and at least a sufficient supply of generalist physicians nationally, there appears to be a strong demand for both specialists and generalists in the Northwest region of the country. This raises questions concerning the use of national averages to inform the education policies in specific regions of the country. More validated measures of demand are needed for future studies.

Data Collection↗
PubMed2003

A pilot randomized, controlled trial of a longitudinal residents-as-teachers curriculum.

PURPOSE: To determine whether a longitudinal residents-as-teachers curriculum improves generalist residents' teaching skills. METHOD: From May 2001 to February 2002, 23 second-year generalist residents in four residencies affiliated with the University of California, Irvine, College of Medicine, completed a randomized, controlled trial of a longitudinal residents-as-teachers program. Thirteen intervention residents underwent a 13-hour curriculum during one-hour noon conferences twice monthly for six months, practicing teaching skills and receiving checklist-guided feedback. In a 3.5-hour, eight-station objective structured teaching examination (OSTE) enacted and rated by 15 senior medical students before and after the curriculum, two trained, blinded raters independently assessed each station with detailed, case-specific rating scales (rating scale reliability = 0.96, inter-rater reliability = 0.78). RESULTS: The intervention and control groups were similar in academic performance, specialty distribution, and gender (chi(2) = 0.434, p =.81). On a five-point Likert scale (5 = best teaching skills), intervention and control residents showed similar mean pretest OSTE scores (2.83 vs. 2.88, p =.736). The intervention group improved their mean overall OSTE scores 22.3% (more than two standard deviations) from 2.83 (pretest) to 3.46 (post-test; p <.0005; 95% CI 0.53 to 0.72). Intervention residents also improved significantly on six of eight OSTE stations. Within the control group, no pretest-to-post-test change achieved statistical significance. Mann-Whitney and Wilcoxon signed-rank tests confirmed these results. CONCLUSIONS: Generalist residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum consistently showed improved OSTE scores. Future research should clarify which aspects of residents-as-teachers curricula most effectively improve educational outcomes.

California↗
PubMed2005

Career plans for trainees in internal medicine residency programs.

PURPOSE: Fewer medical students are pursuing residency training in primary care disciplines. This report describes the career plans of residents enrolled in internal medicine training programs and their reasons for pursuing either generalist or subspecialist career paths. METHOD: From 1998 to 2003, questionnaires were administered to residents participating in the Internal Medicine In-Training Examination. Each year, the survey included questions on career choices. In 2002, residents completed a more detailed survey about the specific reasons for their career choices. The authors report their responses. RESULTS: There has been a steady decline in the percentage of internal medicine residents planning to pursue generalist careers. In 1998, 54% of PGY3s planned to practice general internal medicine compared with 27% in 2003. Strikingly, in 2003, only 19% of PGY1s planned to pursue careers in general medicine. Residents choosing careers as generalists were influenced by opportunities for long-term relationships with patients, a broad content area of practice, caring for ambulatory patients, and time with family. The specific reasons for choosing one subspecialty over another varied greatly among the subspecialty disciplines. Women residents preferred disciplines that allowed more time for family. Both genders were attracted to a particular subspecialty for similar reasons. CONCLUSIONS: There has been a dramatic decrease in the number of internal medicine residents planning to pursue careers in general medicine. This trend will likely continue for the next few years, at least, and may have an impact on the manner in which the health needs of patients are met in the future.

Adult↗
PubMed1995

Graduate education in health policy and management: the University of Massachusetts experience, 1978-1990.

For students in undergraduate and graduate programs in health policy and management, particularly those who wish to be trained as public-health-oriented generalist health administrators, as well as those charged with the responsibility of being their teachers, it is important to consider the trajectory, tensions, and rewards of a career in health policy and management. This article begins by examining what we have learned from earlier research and writing on health policy and management careers and then moves on to analyzing the career history and professional development of 40 graduates of the generalist health policy and management program at the University of Massachusetts School of Public Health. Finally, the article reaches some conclusions about career paths for generalist health administrators trained in at least one school of public health.

Adult↗
PubMed2000

Workforce issues for the academic otolaryngologist.

BACKGROUND: The current medico-economic environment has led to profound changes in our health care system and questions of physician surplus. These issues have particularly affected the academic health care system, as research funding and departmental support have decreased, and many young otolaryngologists are questioning academic careers because of these uncertainties. The current study was undertaken to assess the workforce environment for the academic otolaryngologist, particularly the young physician. METHODS: Surveys were sent to the academic chairmen of all accredited otolaryngology residency programs in the United States, requesting information on faculty appointments--actual and projected-as well as subspecialty appointments and expectations of young faculty. RESULTS: The response rate was 60% (59/98). Faculty additions have been relatively stable from 1994 to 1998, with approximately 37 assistant professor and 5 associate professor positions filled yearly. Faculty additions were the result of departmental expansion in 83% of cases and spanned many subspecialties. The subspecialty positions most frequently added from 1994 to 1998 were generalists (57), head and neck oncologists (53), pediatric otolaryngologists (48), and otologists (39), with generalists filling 15 positions in 1998. Ninety-three percent of programs anticipate faculty additions in the next 5 years; most will be at the assistant professor level (77%), with 30% of positions for generalists, 20% for head and neck oncologists, and 18% for pediatric otolaryngologists. Faculty expectations are primarily clinical, with research being least important. CONCLUSIONS: Academic positions are available for the young otolaryngologist, particularly in the fields of general otolaryngology, head and neck oncology, and pediatric otolaryngology.

Data Collection↗
PubMed1995

The impact of rheumatology in the primary care setting: one rheumatologist's odyssey.

I report my experience during one 6-month period as the sole rheumatologist running a weekly clinic at a small community hospital. The report illustrates the impact of rheumatologic expertise in an environment well-served by generalists and other medical subspecialists. This experience identifies important gaps in the education of generalists in internal medicine residency training programs. In particular, the ability to recognize and distinguish patients with the two most prevalent rheumatic disorders, rheumatoid arthritis and osteoarthritis, must be taught to generalists more effectively by rheumatologists.

Clinical Competence↗
PubMed2005

Women's patterns of provider use across the lifespan and satisfaction with primary care coordination and comprehensiveness.

BACKGROUND: Women have different patterns of provider use across the lifespan, but few studies have investigated women's evaluations of their primary care providers at different ages. OBJECTIVE: We sought to investigate the relationship between patterns of regular provider use and women's satisfaction with primary care across the lifespan. RESEARCH DESIGN: A sample of 1197 women ages 18 to 87 making primary health care visits was surveyed. Satisfaction with primary care in the past year was measured with a subscale the Care Coordination and Comprehensiveness subscale of the Primary Care Satisfaction Survey for Women (PCSSW). Bivariate comparisons and age stratified multivariate ordinal logistic regression models were estimated. RESULTS: Women in their early reproductive years (ages 18 to 34) are more satisfied with care coordination and comprehensiveness when their regular provider is a reproductive health specialist, primarily obstetrician gynecologist (ob/gyn) physicians. The odds of higher satisfaction are reduced with a generalist regular provider (OR = 0.38, P < 0.01), a generalist regular provider plus an ob/gyn (OR = 0.47, P < 0.05), or no regular provider (OR = 0.52, P < 0.05). The pattern of regular provider use is not significantly associated with satisfaction for women in other age categories. CONCLUSIONS: Most adult women see generalists for their primary health care, either alone or in combination with ob/gyns. Among younger women satisfaction is higher when an ob/gyn is the regular provider. Further research must consider women's perspectives on their provider use patterns and the appropriate role of ob/gyns in women's primary care across the lifespan.

Adult↗
PubMed1999

Molecular phylogenetic evidence for the evolution of specialization in anemonefishes.

Anemonefishes (genera: Amphiprion and Premnas; family Pomacentridae) are a group of 28 species of coral reef fishes that are found in obligate symbiosis with large tropical sea anemones. A phylogenetic hypothesis based on morphological analyses of this group suggests that the ancestral anemonefish was a generalist with similar morphology to other pomacentrids, and that it gave rise to other anemonefish species that were more specialized for living with particular species of host anemones. To test this hypothesis we constructed a molecular phylogeny for the anemonefishes by sequencing 1140 base pairs of the cytochrome b gene and 522 base pairs of the 16S rRNA gene for six species of anemonefishes (representatives of all subgenera and species complexes) and two other pomacentrid species. Three methods of phylogenetic analysis all strongly supported the conclusion that anemonefishes are a monophyletic group. The molecular phylogeny differs from the tree based on morphological data in that the two species of specialized anemonefishes (Premnas biaculeatus and Amphiprion ocellaris) were assigned to a basal position within the clade, and the extreme host generalist (Amphiprion clarkii) to a more derived position. Thus, the initial anemonefish ancestors were probably host specialists and subsequent speciation events led to a combination of generalist and specialist groups. Further phylogenetic studies of additional anemonefish species are required to substantiate this hypothesis.

Animals↗
PubMed2005

Morphological evolution, ecological diversification and climate change in rodents.

Among rodents, the lineage from Progonomys hispanicus to Stephanomys documents a case of increasing size and dental specialization during an approximately 9 Myr time-interval. On the contrary, some contemporaneous generalist lineages like Apodemus show a limited morphological evolution. Dental shape can be related to diet and can be used to assess the ecological changes along the lineages. Consequently, size and shape of the first upper molar were measured in order to quantify the patterns of morphological evolution along both lineages and compare them to environmental trends. Climatic changes do not have a direct influence on evolution, but they open new ecological opportunities by changing vegetation and allow the evolution of a specialist like Stephanomys. On the other hand, environmental changes are not dramatic enough to destroy the habitat of a long-term generalist like Apodemus. Hence, our results exemplify a case of an influence of climate on the evolution of specialist species, although a generalist species may persist without change.

Analysis of Variance↗
PubMed2004

Influence of volcanic activity on the population genetic structure of Hawaiian Tetragnatha spiders: fragmentation, rapid population growth and the potential for accelerated evolution.

Volcanic activity on the island of Hawaii results in a cyclical pattern of habitat destruction and fragmentation by lava, followed by habitat regeneration on newly formed substrates. While this pattern has been hypothesized to promote the diversification of Hawaiian lineages, there have been few attempts to link geological processes to measurable changes in population structure. We investigated the genetic structure of three species of Hawaiian spiders in forests fragmented by a 150-year-old lava flow on Mauna Loa Volcano, island of Hawaii: Tetragnatha quasimodo (forest and lava flow generalist), T. anuenue and T. brevignatha (forest specialists). To estimate fragmentation effects on population subdivision in each species, we examined variation in mitochondrial and nuclear genomes (DNA sequences and allozymes, respectively). Population subdivision was higher for forest specialists than for the generalist in fragments separated by lava. Patterns of mtDNA sequence evolution also revealed that forest specialists have undergone rapid expansion, while the generalist has experienced more gradual population growth. Results confirm that patterns of neutral genetic variation reflect patterns of volcanic activity in some Tetragnatha species. Our study further suggests that population subdivision and expansion can occur across small spatial and temporal scales, which may facilitate the rapid spread of new character states, leading to speciation as hypothesized by H. L. Carson 30 years ago.

Animals↗
PubMed2005

Palliative care in the hinterlands: a description of existing services and doctors' attitudes.

OBJECTIVE: To describe palliative care services as they exist in the hinterlands (towns away from regional centres) of Midwest New South Wales, including an estimation of the numbers of cases treated by local doctors, and the service they provide to their patients. Generalist doctors' attitudes to palliative care are also explored, as this information is lacking in the literature but is important for service provision. DESIGN: Descriptive survey. SETTING: Rural primary care and district hospitals. PARTICIPANTS: Generalist doctors in hinterland areas. RESULTS: In total, 38% (19/50) of surveys were returned. "Visiting rights" to the district hospital were held by 78.9% of local doctors, and patients are admitted under the care of their own doctor for symptom control and terminal care, 94.1% and 76.5% of the time, respectively. All doctors surveyed perform home visits for terminally ill patients, and 68.4% make themselves routinely available after hours. Doctors surveyed estimated that they managed a mean of 8.4 deaths due to chronic illness in the past 12 months. Most (78.9%) said that they would continue to manage dying patients even if they had a choice, and they feel between moderately and very satisfied that they provide quality care. However, only 21.1% considered their undergraduate training in palliative medicine to be adequate, and all said that they would refer to a specialist service if it were available. CONCLUSIONS: Generalist rural doctors not only treat many dying patients, but also provide a continuity of care that is rarely seen in other settings. Proposals of models for "rural" palliative care should, therefore, take this unique setting into account. One such suggestion is given in this article.

After-Hours Care↗
PubMed1996

Changes in job aspirations during physician training in Australia.

BACKGROUND: There is uncertainty regarding the effects of physician training on planned practice features of Australian physician trainees, for example plans for urban or rural, full-time or part-time and academic/research or purely clinical practice. These plans may differ between male and female trainees and between generalists and sub-specialists. AIM: To examine the changes in anticipated practice patterns over the course of advanced physician training. METHODS: Longitudinal study of doctors in Australia who passed the Part I clinical examination of the Royal Australasian College of Physicians in 1991, 1992 and 1993, followed annually up until 1995. Changes in future practice plans regarding full- or part-time work, rural or urban practice and pure clinical work or a mixture with research were examined among generalist and specialist trainees and among men and women. Statistical analysis included the calculation of chi square for trend statistics and intraclass correlation coefficients. RESULTS: At least one follow-up questionnaire was received form 80% of the 334 original respondents. The majority had been able to obtain their training job of choice. By the time of last follow-up, around 80% planned to practise in a capital city, indicating a shift during training from those who initially stated no preference. There was also a shift towards combining research with clinical practice and among women wishing to practise part-time only. Generalists were more likely to wish to practise outside a capital city than specialists. CONCLUSIONS: The training programme should be revised so that careers in rural and provincial centres are encouraged and so that it is sensitive to the needs for physicians to develop research capacity. Training and career opportunities should allow all candidates (particularly women) wishing part-time employment to achieve their full career potential.

Adult↗
PubMed1999

Multi-method assessment of access to primary medical care in rural Colorado.

The objectives of this study include conducting an analysis of access to primary medical care in rural Colorado through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analyses examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads that might result from every rural Coloradoan's exclusive use of the nearest generalist physician as a regular source of care. Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files (Census of Population and Housing, 1990), the authors calculated distance to the nearest primary care physician for residents of each of the 1,317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. Straight-line mileage to primary medical care was modest for rural Coloradoans--a median distance of 2.5 miles. Almost two-thirds (65 percent) of the population resided within 5 miles, and virtually all residents (99 percent) were within 30 miles of a generalist physician. However, had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries depict access to primary medical care and corresponding consumer difficulty more fully than in previous studies. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Colorado↗
PubMed2000

Medical training debt and service commitments: the rural consequences.

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

Career Choice↗
PubMed2006

Geographic access to health care for rural Medicare beneficiaries.

CONTEXT: Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. PURPOSE: To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington. METHODS: Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient's and the provider's zone improvement plan codes. FINDINGS: There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Rural residents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists. CONCLUSIONS: Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care.

Aged↗
PubMed2002

Performance parameters for screening and diagnostic mammography: specialist and general radiologists.

PURPOSE: To evaluate performance parameters for radiologists in a practice of breast imaging specialists and general diagnostic radiologists who interpret a large series of consecutive screening and diagnostic mammographic studies. MATERIALS AND METHODS: Data (ie, patient age; family history of breast cancer; availability of previous mammograms for comparison; and abnormal interpretation, cancer detection, and stage 0-I cancer detection rates) were derived from review of mammographic studies obtained from January 1997 through August 2001. The breast imaging specialists have substantially more initial training in mammography and at least six times more continuing education in mammography, and they interpret 10 times more mammographic studies per year than the general radiologists. Differences between specialist and general radiologist performances at both screening and diagnostic examinations were assessed for significance by using Student t and chi(2) tests. RESULTS: The study involved 47,798 screening and 13,286 diagnostic mammographic examinations. Abnormal interpretation rates for screening mammography (ie, recall rate) were 4.9% for specialists and 7.1% for generalists (P <.001); and for diagnostic mammography (ie, recommended biopsy rate), 15.8% and 9.9%, respectively (P <.001). Cancer detection rates at screening mammography were 6.0 cancer cases per 1,000 examinations for specialists and 3.4 per 1,000 for generalists (P =.007); and at diagnostic mammography, 59.0 per 1,000 and 36.6 per 1,000, respectively (P <.001). Stage 0-I cancer detection rates at screening mammography were 5.3 cancer cases per 1,000 examinations for specialists and 3.0 per 1,000 for generalists (P =.012); and at diagnostic mammography, 43.9 per 1,000 and 27.0 per 1,000, respectively (P <.001). CONCLUSION: Specialist radiologists detect more cancers and more early-stage cancers, recommend more biopsies, and have lower recall rates than general radiologists.

Biopsy↗
PubMed2000

Do primary care physicians or specialists provide more efficient care?

Sinusitis is a common health complaint and expenditures for its treatment are high; thus, it is necessary to promote efficient practice behaviours in managing patient care. This study compares resource utilization between primary care physicians and specialists in the treatment of Medicaid sinusitis patients in Virginia. Physician-level data from Virginia Medicaid claim files for 1993 were analysed. The efficiency frontier, representing the best achievable performance in the use of resources for treating sinusitis, is identified using Data Envelopment Analysis. Resource utilization (primary care physician visits, specialist visits, emergency room usage, prescriptions and laboratory tests) and corresponding costs are compared between generalists and otolaryngologists. It was concluded from this study that there are no discernible differences in technical efficiency between generalists and specialists in the treatment of sinusitis. Nevertheless, otolaryngologists are found to be more costly than generalists in treating sinusitis. Variation in both caseload and patient mix might explain variation in use of resources.

Decision Making↗