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PubMedDate not supplied

Academic general pediatrics: from endangered species to advanced scholars of general pediatrics: the report of a consensus conference.

The discipline of academic general pediatrics (AGP) has been the foundation of the medical specialty of pediatrics since those caring for children became differentiated from practitioners of internal medicine. Virtually every academic medical center has been populated with generalist physicians who engage in patient care, teaching, research, administration, and advocacy. Often these individuals served as wise mentors who saw the need for further subspecialization in pediatrics and encouraged the development of academic careers that have resulted in advancing care for infants, children, and adolescents. Beginning with the certification of pediatric cardiology in 1961 to the certification of developmental-behavioral pediatrics in 2000, pediatrics has become increasingly subspecialized and focused. Yet however beneficial the forces of medical specialization have been,1 the value of those pediatricians who have maintained a generalist approach to their work has also been recognized. The role of the academic generalist has undergone change and challenge. A consensus conference was held to explore the evolution of AGP and to plan future directions of the discipline.

Forecasting↗
PubMed2026

Effector loss and gain drives host range at a fitness cost.

Epidemic preparedness depends on tracking microbial evolution that drives shifts in ecological behaviors such as disease emergence. However, the genetic constraints mediating microbial emergence for generalist and specialist behaviors remain poorly described. Here, we addressed this question by combining comparative and functional genomics with phylogeny-based evolutionary analyses of the cereal pathogen Xanthomonas translucens. We show that a generalist X. translucens subgroup arose from a specialist ancestor, and the loss of a single effector gene, xopAL1, contributed to the generalist host expansion by promoting host jump from barley to wheat. Deleting barley-specialist X. translucens xopAL1 recapitulated the host jump to wheat and demonstrates risk across each globally distributed genetic lineage. However, this niche expansion via XopAL1 loss incurs a significant fitness cost to colonize barley. Moreover, the specialist lineage gained an additional effector gene, xopAJ, which enhanced virulence on barley while restricting oat infection, thereby reinforcing niche specialization. We further conducted transcriptomic analysis of wheat and determined that XopAL1 triggers a defense response that involves the reduction of photosynthetic processes. Our work provides an experimentally validated evolutionary framework to understand mechanisms of intergenera host jump. Overall, we demonstrate that single events of gene loss and gain shape ecological behaviors by creating a dynamic trade-off between niche breadth and specialization.

Triticum↗
PubMed2006

Do top-down or bottom-up forces determine Stephanitis pyrioides abundance in urban landscapes?

This study examined the influence of habitat structural complexity on the collective effects of top-down and bottom-up forces on herbivore abundance in urban landscapes. The persistence and varying complexity of urban landscapes set them apart from ephemeral agroecosystems and natural habitats where the majority of studies have been conducted. Using surveys and manipulative experiments. We explicitly tested the effect of natural enemies (enemies hypothesis), host plant quality, and herbivore movement on the abundance of the specialist insect herbivore, Stephanitis pyrioides, in landscapes of varying structural complexity. This herbivore was extremely abundant in simple landscapes and rare in complex ones. Natural enemies were the major force influencing abundance of S. pyrioides across habitat types. Generalist predators, particularly the spider Anyphaena celer, were more abundant in complex landscapes. Predator abundance was related to greater abundance of alternative prey in those landscapes. Stephanitis pyrioides survival was lower in complex habitats when exposed to endemic natural enemy populations. Laboratory feeding trials confirmed the more abundant predators consumed S. pyrioides. Host plant quality was not a strong force influencing patterns of S. pyrioides abundance. When predators were excluded, adult S. pyrioides survival was greater on azaleas grown in complex habitats, in opposition to the observed pattern of abundance. Similarly, complexity did not affect S. pyrioides immigration and emigration rates. The complexity of urban landscapes affects the strength of top-down forces on herbivorous insect populations by influencing alternative prey and generalist predator abundance. It is possible that habitats can be manipulated to promote the suppressive effects of generalist predators.

Animals↗
PubMed2000

Diagnostic radiologists' subspecialization and fields of practice.

OBJECTIVE: The purpose of this study was to explore the diagnostic radiology profession from the perspective of subspecialization and fields of practice. MATERIALS AND METHODS: Data for 1244 practicing diagnostic radiologists were gathered from the American College of Radiology's 1995 Survey of Radiologists. Radiation oncologists, the retired, and residents and fellows were excluded. Responses were weighted to represent all practicing diagnostic radiologists in the United States and were compared with a similar previous survey. RESULTS: More than one quarter (28%) of diagnostic radiologists are subspecialists. Diagnostic radiology subspecialists were more likely than generalists to have fellowship training, work in center cities, work in large groups, and be employed by an academic institution. They were also generally younger and provided a narrower range of imaging services than generalists. CONCLUSION: Although most diagnostic radiologists are generalists, subspecialization will likely continue to grow.

Adult↗
PubMedDate not supplied

Faculty preparation: is clinical specialization a benefit or a deterrent to quality nursing education?

This article presents a point of view regarding the impact of specialty preparation at the master's level on performance as a faculty member in an entry-level program. Essentially, the focus in depth on a particular branch of nursing practice restricts the perception of the individual to the role and demands of the beginning generalist nurse. Continued attention to the development of expertise in the specialty reduces the effectiveness of the faculty member to develop a comprehensive view of the knowledge required by the beginning generalist nurse. Because faculty prepared in this manner also frequently lack formal knowledge regarding teaching and curriculum, they continue to teach in the same manner as they were taught, often with an eye toward teaching the extensive content taught in the specialty program. More broadly based master's degree programs that couple advanced nursing knowledge with nursing education content and skill can foster in new nurse faculty a more comprehensive picture of the learning needs of beginning generalist nurses.

Clinical Competence↗
PubMed1997

What can be done about home health fieldwork?

The literature indicates that health care is moving away from institutional care and specialization to the community and home where providers need generalist competencies. As educators strive to prepare students for this environment, fieldwork experiences in the community and home are opportunities for students to develop generalist competencies. Because of the current scarcity of fieldwork sites, in general, scheduling placements is difficult. As educators seek new sites, home health settings and therapists who provide home health care as a component of their service need to be considered. Home health occupational therapy requires a practitioner to adopt a holistic perspective in order to assist clients to function optimally in their home environment. Because a large number of students work in addition to taking classes, they can be encouraged to find jobs as home health aides or chore providers as part-time employment before and during their didactic education. This work experience can help them to acculturate to the home setting. By encouraging students' participation in home health experiences, educators are helping to facilitate generalist competencies.

Home Care Services↗
PubMed2001

Reforming the core clerkship in internal medicine: the SGIM/CDIM Project. Society of General Internal Medicine/Clerkship Directors in Internal Medicine.

Dramatic changes in health care have stimulated reform of undergraduate medical education. In an effort to improve the teaching of generalist competencies and encourage learning in the outpatient setting, the Society of General Internal Medicine joined with the Clerkship Directors in Internal Medicine in a federally sponsored initiative to develop a new curriculum for the internal medicine core clerkship. Using a broad-based advisory committee and working closely with key stakeholders (especially clerkship directors), the project collaborators helped forge a new national consensus on the learning agenda for the clerkship (a prioritized set of basic generalist competencies) and on the proportion of time that should be devoted to outpatient care (at least one third of the clerkship). From this consensus emerged a new curricular model that served as the basis for production of a curriculum guide and faculty resource package. The guide features the prioritized set of basic generalist competencies and specifies the requisite knowledge, skills, and attitudes/values needed to master them, as well as a list of suggested training problems. It also includes recommended training experiences, schedules, and approaches to faculty development, precepting, and student evaluation. Demand for the guide has been strong and led to production of a second edition, which includes additional materials, an electronic version, and a pocket guide for students and faculty. A follow-up survey of clerkship directors administered soon after completion of the first edition revealed widespread use of the curricular guide but also important barriers to full implementation of the new curriculum. Although this collaborative effort appears to have initiated clerkship reform, long-term success will require an enhanced educational infrastructure to support teaching in the outpatient setting.

Clinical Clerkship↗
PubMed2005

Quality of HIV care provided by nurse practitioners, physician assistants, and physicians.

BACKGROUND: Nurse practitioners (NPs) and physician assistants (PAs) are primary care providers for patients with HIV in some clinics, but little is known about the quality of care that they provide. OBJECTIVE: To compare the quality of care provided by NPs and PAs with that provided by physicians. DESIGN: Cross-sectional analysis. SETTING: 68 HIV care sites, funded by Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Title III, in 30 different states. PARTICIPANTS: The authors surveyed 243 clinicians (177 physicians and 66 NPs and PAs) and reviewed medical records of 6651 persons with HIV or AIDS. MEASUREMENTS: 8 quality-of-care measures assessed by medical record review. RESULTS: After adjustments for patient characteristics, 6 of the 8 quality measures did not statistically significantly differ between NPs and PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative testing and Papanicolaou smears were statistically significantly higher for NPs and PAs (0.63 and 0.71, respectively) than for infectious disease specialists (0.53 [P = 0.007] and 0.56 [P = 0.001], respectively) or generalist HIV experts (0.47 [P < 0.001] and 0.62 [P = 0.025], respectively). Nurse practitioners and PAs had statistically significantly higher performance scores than generalist non-HIV experts on 6 of the 8 quality measures. LIMITATIONS: These results may not be generalizable to care settings where on-site physician HIV experts are not accessible or to measures of more complex clinical processes. CONCLUSIONS: For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV experts and generally better than physician non-HIV experts. Nurse practitioners and PAs can provide high-quality care for persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and either participation in teams or other easy access to physicians and other clinicians with HIV expertise.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Referrals by general internists and internal medicine trainees in an academic medicine practice.

Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed.

Academic Medical Centers↗
PubMed1999

[To better integrate prevention into general medicine in deprived milieus].

Generalists occupy a strategic position in the area of prevention within the general population, and among disadvantaged areas in particular. Yet, practice shows that this position is not a given, as the socio-cultural gap separating doctor and patient renders communication particularly difficult in this context. In order to analyse this situation, a review of the literature, surveys among generalists, and a European seminar were carried out. This article deals with the definition of "disadvantaged environments" by the practitioner, practices in prevention in disadvantaged environments and their related obstacles, and tracks for improving prevention in disadvantaged environments by visits with a generalist.

Attitude of Health Personnel↗
PubMed2001

Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities.

OBJECTIVE: Our goal was to compare the quality of diabetic care received by patients in rural and urban communities. STUDY DESIGN: We performed a retrospective analysis of claims data captured by the Medicare program. POPULATION: We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994. OUTCOME MEASURES: The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination. RESULTS: A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. CONCLUSIONS: Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate-but not excessive-supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.

Aged↗
PubMed2001

National estimates of physician assistant productivity.

Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.

Ambulatory Care↗
PubMed2001

Impact of a first-year primary care experience on residency choice.

We designed a retrospective cohort study of first-year medical students to assess the impact of a community-based primary care course, Introduction to Primary Care (IPC), on residency choice. In the group that took IPC (n=282), 48.2% entered generalist residencies (internal medicine, pediatrics, family medicine, or medicine/pediatrics), compared to 38.2% in the group that wanted IPC (n=398) and 39.6% in the group that did not want IPC (n=245). Controlling for gender, students who took IPC had a 40% higher odds of selecting a generalist residency than those who wanted to take IPC (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.04 to 1.95). There was no difference between those who wanted IPC and those who did not (OR, 1.08; CI, 0.78 to 1.52). The community-based primary care experience was positively associated with students' selection of generalist residencies.

Adult↗
PubMed2002

Physician job satisfaction, dissatisfaction, and turnover.

OBJECTIVES: We studied how physicians' relative satisfaction and/or dissatisfaction with 10 distinct aspects of their work protected against or promoted their plans for leaving their jobs. STUDY DESIGN: Cross-sectional mail survey. POPULATION: A total of 1939 practicing generalists and specialists across the United States. OUTCOME MEASURED: We used logistic regression analysis to assess whether physicians in the top and bottom quartiles of satisfaction for each of 10 aspects of their work and communities were more or less likely to anticipate leaving their jobs within 2 years, compared with physicians in mid-satisfaction quartiles. Separate analyses were compiled for generalists vs specialists, and physicians by age groups (27-44 years, 45-54 years, and 55 years and older). RESULTS: Generalists and specialists had generally comparable levels of satisfaction, whereas physicians in the oldest age group indicated greater satisfaction than younger physicians in 8 of the 10 work areas. One quarter (27%) of physicians anticipated a moderate- to-definite likelihood of leaving their practices within 2 years. The percentage that anticipated leaving varied with physicians' age, starting at 29% of those 34 years or younger, steadily decreasing with age until reaching a nadir of 22% of those from 45 to 49 years, then reversing direction to steadily increase thereafter. Relative dissatisfaction with pay and with relationships with communities was associated with plans for leaving in nearly all physician groups. For specific specialty and age groups, anticipated departure also correlated with relative dissatisfaction with other selected areas of work. CONCLUSIONS: To promote retention, these data suggest that physicians and their employers should avoid physician dissatisfaction in particular. Building particularly high levels of satisfaction generally is not helpful for this end. Avoiding relative dissatisfaction with pay and with community relationships appears broadly important.

Adult↗
PubMed2003

Physicians' reports of their experience with health plan care management practices.

OBJECTIVE: To determine the availability of care management practices in various practice settings, the degree to which physicians report that these practices are useful, and whether physicians' reports vary by their relationships with health plans. STUDY DESIGN: Cross-sectional survey. PARTICIPANT: In 2001, we surveyed generalist and specialist physicians serving commercial, Medicaid, and Medicare patients. This report focuses on the responses of 2134 physicians (1252 generalists, 882 specialists) who contracted with independent practice associations and preferred provider organizations. MEASURES: Physicians were asked about the availability, accuracy, and usefulness of specified care management practices. The responses were analyzed according to their relationships with their health plan. RESULTS: Generalists, physicians with a higher percentage of health plan patients, and physicians who reported that health plans sought their views were more likely to report that they used care management practices. The majority who used these practices found them somewhat or very useful. Guidelines and disease management were among the most commonly available and most highly rated care management practices. Physicians' ratings of the usefulness of practice reports were associated with their perceptions of the reports' accuracy and with whether health plans sought their views on other aspects of the care management process. CONCLUSION: The stronger a physician's relationship with a health plan, the more positive the physician's experience with care management practices and policies was. The concordance between the types of available practices and physicians' ratings suggests that health plans and physicians agree about how to improve the quality of care.

Adult↗
PubMed2004

[Treatment of patients with chronic obstructive pulmonary disease (COPD) by primary care physicians].

A number of recommendations for the treatment of chronic obstructive pulmonary disease (COPD) present the different therapeutic alternatives according to the severity of the condition. It is not entirely clear when the generalist should consult the specialist. This can be important particularly when the health care system is centered in the role of generalists and lack of clarity may be a factor in the deficient use of recommendations. The purpose of this review is to provide evidence of the efficacy and effectiveness for therapeutic approaches distilling from randomized controlled trials, observational trials and guidelines or meta-analyses. The emphasis is on the identification of clinical and physiological criteria that generalists should use to identify candidates for possible consultation with specialists.

Bronchodilator Agents↗
PubMed1989

Dietetic specialization: opinions of directors of departments of dietetics.

The need for specialists in dietetic practice was studied by surveying a stratified, random sample of 750 directors of departments of dietetics from nonfederal, general medical-surgical hospitals with more than 75 beds. The response rate was 72%. The majority of respondents were directors who considered themselves generalists. Five demographic variables used in data analysis were hospital size, education level, registration status, years of experience, and perception of practice as generalist or specialist. Student's t-test and analysis of variance were the principal methods of statistical analysis. Results indicated that respondents supported dietetic specialization; however, they emphasized the value of undergraduate generalist preparation as enhancing job performance and preventing fragmentation of the profession. Respondents indicated that specialization should follow professional work experience and additional education. Respondents stressed that The American Dietetic Association should be responsible for determining the process of dietetic specialization. Education level was the variable most likely to affect response. Respondents with education beyond the baccalaureate level were more likely than those with only a bachelor's degree to agree that specialization should occur after professional experience and at the graduate level.

Analysis of Variance↗
PubMed1995

Personal values of exemplary family physicians: implications for professional satisfaction in family medicine.

BACKGROUND: Personal social values have been identified as important determinants of generalists' specialty choice. However, the personal values or "guiding principles" of generalist physicians have not been identified scientifically. To establish a benchmark, we measured the personal values of exemplary family physicians because they serve as role models for current and future physicians. We also explored the relationship between personal values and practice satisfaction. METHODS: We obtained a list of 330 family physicians nominated for the American Academy of Family Physicians' (AAFP) Family Doctor of the Year award for the years 1988 through 1993. We asked them to complete the Schwartz Values Questionnaire, a 56-item instrument for measuring personal values. They also answered three questions concerning practice satisfaction. RESULTS: The return rate was 83%. The physicians' mean age was 63 years. They had been in practice an average of 34 years, 93% were male, and 52% practiced in rural areas. Honesty was rated as the most important of the 56 values, and social power as the least important. Of the 10 value types (groups of common values), the responding physicians rated "Benevolence" as most important and "Power" as least important. Practice satisfaction correlated positively with the Benevolence value type (r = .21, P = .001) and negatively with the Power value type (r = -.15, P = .023). CONCLUSIONS: Of the 10 value types, Benevolence was rated the most important and Power the least important by exemplary family physicians, and both value types also correlated, positively and negatively, respectively, with their practice satisfaction. These results have implications for the selection, training, and career satisfaction of generalist physicians.

Adult↗