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PubMed1994

How will graduate medical education reform affect specialties and geographic areas?

OBJECTIVES: To project specialty and geographic impacts of workforce reform proposals on the practice output of graduate medical education (GME). DESIGN: A demographic life-table model to predict GME output was developed using 1987 cohort data from the Association of American Medical Colleges Annual GME Census. The 1992 GME cohort was used as a baseline to compare the simulated impact of alternate specialty and regional policies. SETTING: Allopathic and osteopathic GME programs in the United States. MAIN OUTCOME MEASURE: Projected number of physicians (MDs and DOs) entering nine categories of practice specialty at the conclusion of GME. RESULTS: If GME input is reduced to 110% of US medical graduates with 55% entering practice as generalists (including obstetrics and gynecology), then the total number of first-year positions will decline from 24,433 to 18,783, and the total number of residents in GME would decline from 103,858 to 80,699 at equilibrium. Even with a 110% restriction on GME input, the overall physician-to-population ratio will continue to grow, albeit at a much slower rate. The number of generalists leaving GME annually would increase by 742 (9%) and the number of specialists would decline by 6517 (44%). At the regional level, allocating GME positions by prorating to the current distribution results in less change than would prorating positions to regional populations. CONCLUSIONS: Achieving national goals of reduced aggregate physician production, reduced specialist supply, and generalist increases will require significant alterations in the GME pool. Adequate time and funding for resident substitution will be required for hospitals to develop alternate models of providing service to allow national workforce goals to be met.

Demography↗
PubMed1994

Preparing the osteopathic academic health centers for healthcare reform.

Healthcare reform proposals introduced in the House and Senate, put forward by foundations, professional associations and study groups, all call for medical schools to train more generalists. As these agents make recommendations for change, they are studying the osteopathic medical education model with fresh interest because of its success in maintaining more than 60% of its graduates in primary care practice. Most students of reform place the blame for producing too many specialists and sub-specialists squarely on the academic health centers. The authors trace the development of academic health centers and compare and contrast the models developed in the osteopathic and allopathic medical settings. They enumerate the strengths in the osteopathic education model which have contributed to our favorable balance of generalists to specialists. However, they argue that specific changes in the osteopathic academic health center are essential if we are to retain leadership in generalist education under healthcare reform.

Academic Medical Centers↗
PubMed1993

Louisiana's need for primary care physicians: let's not forget the role of medical education.

Louisiana's need for primary care physicians remains among the highest in the nation. The state's rural nature, the aging of current family and general practitioners, the low output of new family physicians, and an increased demand for generalists as a result of changes in health care delivery has exacerbated the situation. Despite the need, the state's medical schools have lagged in terms of the entry of its graduating medical students into primary care, especially family medicine. The tertiary nature of the medical school setting and lack of generalist role models on the faculty have contributed to the declining interest in primary care. Several encouraging changes are underway in medical education in Louisiana that may support the production of more generalists, although the pipeline is long.

Career Choice↗
PubMed1996

Academia's chilly climate for primary care.

OBJECTIVE: To describe the attitudes toward and perceptions of primary care education and practice among academic health center constituents. DESIGN AND PARTICIPANTS: Descriptive study using confidential telephone interviews (October 1993 to March 1994) of national stratified probability samples of first- and fourth-year medical students, residents, clinical faculty, internal medicine and pediatrics residency training directors and chairs, and deans (N=2293). RESULTS: Five areas were examined: respondents' specialty orientation, attitudes toward the competence of primary care physicians, encouragement and positive regard for primary care, exposure to primary care-related educational experiences, and socioemotional orientation. The response rate was 84%. Respondents generally perceive primary care tasks as not requiring high levels of expertise; nearly half believe that generalists are not the best physicians to manage patients with serious illness and that the quality of primary care research is inferior to that in other fields. Attitudes are more positive toward the quality of primary care teaching. Learners perceive little encouragement for generalist careers and negative attitudes toward generalists among faculty, and view the quality of their primary care training as inferior to that for specialty practice. Those who have progressed further in the academic medicine hierarchy generally report lower levels of socioemotional orientation than individuals at earlier phases of career development. CONCLUSIONS: Despite changes in the health care system and in education, students and residents encounter an atmosphere that is chilly toward primary care. If medical educators seek to optimize enthusiasm and preparation for primary care careers, they must develop approaches to changing the attitudes, values and composition of their faculties.

Academic Medical Centers↗
PubMed1997

Obstetrics in general practice. A rural perspective.

Obstetrics is one of the most demanding yet rewarding disciplines required of rural general practice although rising medical indemnity fees combined with medico-legal interest in this discipline make the current rural generalist obstetricians a threatened species. These factors, plus the difficulty generalist registrars have in obtaining good procedural training in this specialist field make obstetric practice less than attractive for future rural general practitioners. This article provides a brief overview of rural obstetric practice from the perspective of a rural generalist obstetrician with 18 years experience. Case studies are used to highlight the challenges of this field.

Australia↗
PubMed1995

Scratching the surface: mental health training for rural health workers.

This paper will describe the Mental Health Training for Rural Health Workers Project that was completed in 1995 under the Rural Health Support Education and Training Program. The lack of specialist mental health services in rural areas means that generalist health workers need to provide mental health services in rural communities. Generalist health workers often feel ill-equipped to help people who require mental health services. The aim of this project was to provide generalist workers in rural areas with practical skills and knowledge in order to help people with mental health disorders and promote positive mental health. The project involved an initial needs survey, the development of education and training material, the implementation of the training, and evaluation of the project.

Clinical Competence↗
PubMed2026

The impact of non-native trees on galling and herbivory in New York City across space and time.

Cities and suburbs frequently plant native and non-native trees as foundation species, with non-natives cultivated in these areas for centuries while remaining non-invasive. Although previous research has found that native trees often host more arthropods, studies have not simultaneously looked across space and time to determine the consistency of tree origin on urban arthropods. We combined varied methods across spatial and temporal scales in New York City to test if native tree leaves consistently have more insect and mite interactions than long-established non-native trees, predicting stronger effect sizes for specialists (galling arthropods) than generalists (herbivory). We examined (1) congeneric species pairs, controlled for growing conditions and stoichiometry in an arboretum, (2) diverse oaks at a botanical garden, (3) community science records across Brooklyn, and (4) herbarium specimens from 1883 through present across the city. Across spatiotemporal scales, we found consistent results. Specialist interactions were striking: contemporary native trees supported numerous galling species, while only one congeneric non-native species hosted any galls. For generalists, contemporary native trees had equivalent to slightly greater herbivory. Over the last century, herbarium records showed that herbivory increased on non-native trees to nearly the level of natives, whereas native trees increased in gall abundance while non-native trees remained rarely galled. Our results demonstrate the impact of tree origin on tree-arthropod interactions in a real-world urban setting, with far fewer galls even when non-native tree species have been cultivated locally for centuries. Our findings will help city planners and property owners confidently choose native trees to promote arthropod biodiversity.

Trees↗
PubMed2005

Teaching the psychosocial aspects of care in the clinical setting: practical recommendations.

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic "CAARE MORE": Connect personally with the trainee; Ask psychosocial questions and Assess the trainee's knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainee's affect and behavior; Reflect and provide feedback on doctor-patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor-trainee teaching skills that are recommended parallel good doctor-patient interaction skills. They can be used during both preceptor-trainee and preceptor-trainee-patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.

Clinical Medicine↗
PubMed1999

Resident expectations of morning report: a multi-institutional study.

BACKGROUND: Morning report, a cornerstone of inter nal medicine residency programs for many years, involves a diverse group of teachers and learners with heterogeneous learning goals. METHODS: We distributed a self-administered, cross sectional survey to internal medicine residents to clarify the objectives of the learners at morning report. We selected a convenience sample of internal medicine residents at community- and university-based programs Questions were answered in a Likert scale or multiple-choice format. RESULTS: Residents from 13 residency programs in 7 states participated. We received 356 completed surveys, which represented a 63% response rate. The house staff in our sample preferred that half of the guest attending physicians be generalists. They indicated that the primary function of morning report should be educational, and preferred to discuss the management of a few interesting cases rather than review all patients admitted the previous day. The majority of respondents (60.8%) favored a stepwise presentation of cases to simulate the chronology of receiving information. Disease process, diagnostic workup, and evaluation of tests and procedures were all considered important topics for discussion, while medical ethics and research methods were viewed as less important. Responses varied little when stratified by sex, postgraduate year, type of residency program, subspecialty fellowship plans, or location of medical school. CONCLUSIONS: Residents from a diverse group of programs expressed remarkably similar opinions about morning report. Consistent with the recently increased emphasis on ambulatory care and general internal medicine in residency training, they expressed a desire for about 50% of the guest attending physicians to be generalists. In addition, they preferred a style in which challenging cases were presented in a stepwise manner.

Adult↗
PubMed2001

Patients' role in the use of radiology testing for common office practice complaints.

BACKGROUND: Radiological studies are an important component of ambulatory medical costs, and guidelines often focus on their appropriate use. However, little is known about the correlates of the use of those services, particularly the influence of patients' preferences on physicians' utilization decisions. OBJECTIVES: To study patients presenting for outpatient treatment of respiratory problems and low back pain, and to examine the magnitude of the effect of the patients' perceived need for radiological studies (radiology preference score) on use of those services. DESIGN: Cross-sectional survey. SETTING: Office practices of generalist physicians in predominantly rural areas of 8 states. PARTICIPANTS: A total of 52 generalist physicians agreed to enroll consecutive Medicare-eligible patients making office visits for respiratory problems or low back pain. Of 1785 eligible patients invited to participate, 132 (7%) refused and 1137 (69%) of 1653 returned questionnaires. MEASUREMENTS: Radiology utilization rates (plain film, computed tomographic scan, or magnetic resonance image scan) were determined by patient self-report. To assess perceived need for radiological studies, we asked patients how necessary they believed an x-ray film was in the evaluation of 4 common complaints (respiratory problems, low back pain, knee pain, and knee swelling). A summary radiology preference score was created from 3 of the 4 items, excluding the item referring to the patients' index complaint. RESULTS: Six hundred fifteen respiratory and 522 low back pain patients were enrolled; mean ages were 69 and 64 years, respectively. Radiology utilization rates were 37% for respiratory and 26% for low back pain patients. In multiple logistic regression models, for respiratory patients radiology utilization was related significantly to the radiology preference score (odds ratio [OR] for fourth quartile compared with first quartile, 1.94; 95% confidence interval [CI], 1.11-3.37; P = .02), to having a physician who owned radiology equipment (OR, 1.81; 95% CI, 1.23-2.66; P = .002), and current smoking (OR, 1.58; 95% CI, 1.04-2.41; P = .03). For low back pain patients, radiology utilization was significantly related to the radiology preference score (OR for fourth compared with first quartile, 2.55; 95% CI, 1.29-5.06; P = .007), bothersomeness of the pain (OR for fourth compared with first quartile, 3.74; 95% CI, 1.74-8.04; P<.001), and a diagnosis of osteoporosis (OR, 1.67; 95% CI, 1.01-2.75; P = .04). CONCLUSIONS: Patients' perceived need for radiological studies was significantly associated with use of those services for outpatients with respiratory problems and low back pain. These findings suggest that patients communicate their wishes to physicians, either directly or indirectly, regarding services they think are necessary. Differences in physicians' adherence to guidelines regarding radiology utilization may in part reflect variations in patients' perceived need for those services. Efforts to educate patients about when radiological studies are medically indicated may be an important complement to practice guidelines or other utilization-related financial incentives.

Aged↗
PubMed2003

Time and money: a retrospective evaluation of the inputs, outputs, efficiency, and incomes of physicians.

BACKGROUND: Physicians' concerns with the health care system focus on having less time with their patients and needing to work harder to maintain incomes. We sought to determine whether physicians are working longer hours and whether their incomes are declining. METHODS: Using survey data, we conducted a retrospective analysis of physician inputs, outputs, efficiency, and incomes for generalists, general internists, general surgeons, pediatricians, and obstetrician-gynecologists from 1987 to 1998. RESULTS: Physician inputs (as measured by the average hours worked in professional activities) showed little absolute change across specialties over time. Outputs (as measured by the total number of patient visits per week) decreased between 9% and 28%, depending on the specialty. Efficiency (the proportion of time spent in direct patient care and the amount of time spent during a typical office visit) remained stable over the time examined. Consumer price index inflation-adjusted annual incomes increased considerably over the time period examined (42% for general internists, 28% for pediatricians, 13% for generalists, and 8% for general surgeons); only obstetricians-gynecologists showed a net loss of annual income when adjusting for inflation (a 6% loss). CONCLUSIONS: Our findings do not confirm the prevailing concern that physicians are working harder or longer or that their incomes are declining, but they offer an explanation of how physicians are maintaining incomes without increasing work inputs. There is a great deal of dissatisfaction with the health care system among physicians; exploration of perceptual reasons for that dissatisfaction may outline a course of action needed to resolve it.

American Medical Association↗
PubMed2005

Disparities despite coverage: gaps in colorectal cancer screening among Medicare beneficiaries.

BACKGROUND: Despite its effectiveness in reducing mortality, colorectal cancer (CRC) screening rates are low, especially among low-income and minority groups; however, physician recommendation can increase screening rates. METHODS: We performed a multilevel analysis of the Medicare Current Beneficiary Survey data linked to Medicare claims and the Area Resource File to identify determinants of racial and socioeconomic disparities in CRC screening among 9985 Medicare Parts A and B beneficiaries with a usual physician. Recent CRC screening was defined as receipt of either a home fecal occult blood test, flexible sigmoidoscopy, or colonoscopy at recommended intervals. RESULTS: Unadjusted rates of screening were 48% for white and 39% for black beneficiaries (P<.001). Racial differences in CRC screening receipt were eliminated after adjustment for socioeconomic status as measured by income and education. Socioeconomic status disparities decreased but remained significant after adjustment for personal and health system factors. Awareness of CRC (adjusted odds ratio, 2.76; 95% confidence interval, 2.29-3.33) and having a primary care generalist (vs another specialist) as one's usual physician (adjusted odds ratio, 1.31; 95% confidence interval, 1.12-1.53) were associated with higher odds of screening, controlling for other factors. The odds of screening were also higher among those whose usual physician was rated more highly on information-giving skills. CONCLUSIONS: Racial differences in CRC screening rates among Medicare beneficiaries with a usual physician are explained by differences in socioeconomic status. Beneficiaries with a primary care generalist as their usual physician had higher rates of CRC screening receipt. Increased efforts to make Medicare beneficiaries aware of the benefits of CRC screening may capitalize on the associations found in this study between CRC knowledge, physician information giving, and timely screening.

Aged↗
PubMed1993

The perspectives of current trainees in combined internal medicine-pediatrics. Results of a national survey.

OBJECTIVE: To gather information from combined internal medicine-pediatric residents about their application process for residency, their perceptions of the stressors during residency, and their future plans. DESIGN: Survey of all combined internal medicine-pediatric residents-in-training in the 1989-1990 academic year. PARTICIPANTS: Fifty-four percent of residents-in-training responded to the survey, representing 70% of the programs. RESULTS: Combined residents often investigate and rank other generalist residences. However, internal medicine is significantly (P < .005) considered more often than pediatrics or family medicine. Sixty percent of combined residents do not anticipate further training beyond the 4 years and expect to practice both specialties. The majority of those interested in a subspecialty expect to continue to combine internal medicine and pediatrics in their subspecialty practice. Switching services during the residency engenders stress. Factors that decrease stress include more frequent switches and increasing seniority. Switching from pediatrics to internal medicine is more stressful (P < .0001) than switching to pediatrics from internal medicine. The residents considered ambulatory training sites and a specific coordinator for the program to be the most important features of the residency. CONCLUSIONS: Combined internal medicine-pediatric programs continue to attract a small cohort of well-qualified US medical school graduates, the majority of whom intend to practice as generalists in both pediatrics and internal medicine.

Adult↗
PubMed1998

Physicians' experiences and beliefs regarding informal consultation.

CONTEXT: Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of and beliefs about informal consultation. DESIGN: Survey mailed in July 1997. PARTICIPANTS: Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about informal consultation. RESULTS: Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P<.001) and were asked to provide fewer (2 vs 5 per week; P<.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). CONCLUSIONS: Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.

Humans↗
PubMedDate not supplied

Quality of care for patients with rheumatoid arthritis.

CONTEXT: Patients with rheumatoid arthritis are at risk for substantial morbidity because of their arthritis and premature mortality due to comorbid diseases. However, little is known about the quality of the health care that these patients receive. OBJECTIVE: To assess the quality of the health care that rheumatoid arthritis patients receive for their arthritis, comorbid diseases, and health care maintenance and to determine the effect of patterns of specialty care on quality. DESIGN, SETTING, AND PARTICIPANTS: Historical cohort study of 1355 adult rheumatoid arthritis patients enrolled in the fee-for-service or discounted fee-for-service plans of a nationwide US insurance company. Patients were identified and followed up through administrative data between 1991 and 1995. MAIN OUTCOME MEASURES: Quality scores for arthritis, comorbid disease, and health care maintenance were developed from performance on explicit process measures that related to each of these domains and described the percentage of indicated health care processes performed within each domain during each person-year of the study. RESULTS: During 4598 person-years of follow-up, quality scores were 62% (95% confidence interval [CI], 61%-64%) for arthritis care, 52% (95% CI, 49%-55%) for comorbid disease care, and 42% (95% CI, 40%-43%) for health care maintenance. Across domains, care patterns including relevant specialists yielded performance scores 30% to 187% higher than those that did not (P<.001) and 45% to 67% of person-years were associated with patterns of care that did not include a relevant specialist. Presence of primary care without specialty care yielded health care maintenance scores that were 43% higher than those for patterns that included neither primary nor relevant specialty care (P<.001). CONCLUSIONS: In this population, health care quality appears to be suboptimal for arthritis, comorbid disease, and health care maintenance. Patterns of care that included relevant specialists were associated with substantially higher quality across all domains. Patterns that included generalists were associated with substantially higher quality health care maintenance than patterns that included neither a generalist nor a relevant specialist. The optimal roles of primary care physicians and specialists in the care of patients with complex conditions should be reassessed. JAMA. 2000;284:984-992

Adult↗
PubMed2002

Use of referral reply letters for continuing medical education: a review.

INTRODUCTION: Referrals between generalists and specialists are a central component of the health care system and necessitate effective communication between the involved providers. Despite the high prevalence of patient referrals and their crucial role in continuity and quality of care, the medical literature demonstrates that generalists may receive little or no information about the care their patients received and little information about the appropriateness of the referral or recommendations for follow-up care. General practitioners (GPs) prefer teaching that is directly related to their clinical work rather than traditional continuing education such as formal lectures. The purpose of this review is to assess the role of referral reply letters in the continuing education of GPs. METHODS: A comprehensive literature search was conducted to November 2001 using MEDLINE, EMBASE, the Cochrane Library, and the Research and Development Resource Base developed by Continuing Education, Faculty of Medicine, University of Toronto, to identify studies that examined the use of referral letters for the transfer of information from specialists to referring physicians. Data on methodology, unit of analysis, main outcome measures, and results were extracted. RESULTS: Of 1,250 articles retrieved, 9 met the eligibility criteria. Three of these analyzed the content of referral reply letters and 6 described the results of surveys of general and specialty physicians. DISCUSSION: Little educational content is currently included in letters from specialists to referring GPs. GPs are receptive to the use of referral replies as sources of learning.

Canada↗
PubMed2006

Distribution of substance P reveals a novel subdivision in the hippocampus of parasitic South American cowbirds.

Parasitic cowbirds monitor potential hosts' nests and return to lay when appropriate, a task that is likely to involve spatial recall. Seasonal and sexual behavioral variations in the cowbirds correlate with anatomical changes in the hippocampal formation. During the breeding season, parasites have larger hippocampal formations than nonparasites. In parasitic species in which females alone perform nest bookkeeping, females have larger hippocampal formations than males. We investigated the distribution of the neuropeptide substance P (SP) in three sympatric cowbirds: two obligate parasites (shiny cowbird and screaming cowbird) and one nonparasite (bay-winged cowbird). Distribution of SP was similar to that in other songbirds, except for a previously undescribed field of dense SP-rich terminals within the hippocampus that we call the hippocampal SP terminal field (SPh). We found robust species differences in the volume of this new area, measured relative to the remainder of the telencephalon. SPh was largest in the generalist parasite (shiny cowbird) and smallest in the nonparasitic species (bay-winged cowbird). In the specialist parasite (screaming cowbird), SPh was smaller than in the generalist parasite but larger than in the nonparasitic species. SPh overlaps with two subdivisions described in the pigeon that have been related to the mammalian dentate gyrus and subiculum. The area containing SPh receives a major input from the lateral mammillary nucleus, which is probably the avian equivalent of the mammalian supramammillary nucleus (SUM), the main source of extrinsic SP input to mammalian hippocampus. SPh may be the termination of a pathway homologous to the SP-rich projection from SUM to the hippocampus in mammals.

Animals↗
PubMed2002

Developmental changes in the structure and function of the central olfactory system in gregarious and solitary desert locusts.

Desert locusts are guided by olfactory cues in different behavioural contexts. In order to understand the basis for the variable olfactory guided behaviour displayed by different developmental stages and by solitary and gregarious locusts, we investigated their central olfactory system with neuroanatomical and neurophysiological methods. The primary olfactory centre of the brain, the antennal lobe (AL), increases in size during development due to an increased number and size of glomeruli. These glomeruli are innervated by a constant number of projection neurons that display increased dendritic arborizations during the development of the locust. The anatomical parameters do not differ between gregarious and solitary locusts. In parallel with the observed neuroanatomical changes, neurophysiological changes in response spectra and response specificity of AL neurons were found. During development, the percentage of neurons responding specifically to aggregation pheromone components decreases, whereas an increase in both pheromone-generalists and plant-pheromone generalist neurons is observed. The percentage of neurons responding to green leaf volatiles, however, remains constant. A decrease in the number of nymph blend-specific neurons was also observed. Our data show that anatomical and physiological properties of the AL and its neurons to a large extent reflect the changes in olfactory guided behaviour during development and between phases. The majority of our results are also in accordance with findings that the number of olfactory receptor neurons increases during development, resulting in increasing convergence on AL neurons.

Animals↗