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PubMed1994

A fourth year of training in ambulatory medicine: the University of Washington experience.

Postresidency training in ambulatory general internal medicine has been proposed as a means to enhance the generalist skills of internal medicine graduates. At the University of Washington, a fourth year of training in ambulatory medicine has been offered since 1967. The resident training year provides a core experience in general internal medicine as well as the opportunity for elective experiences in subspecialties and other allied specialties. Graduates of this year of experience in ambulatory training were surveyed to determine current practice patterns and retrospective evaluation of the program; responses were received from 36 of 52 graduates (69%). Among respondents, 50% are general internists, 39% subspecialists, and 11% in other practice specialties. Eight respondents (22%) are practicing in rural communities. Respondents identified the specialized training in outpatient medicine as the primary strength of the additional training year. Many reported using the year to gain additional training tailored to their future practice. The fourth year of ambulatory training thus represents an efficient means to provide additional training to internists planning careers in general internal medicine. It can serve a variety of purposes, including preparation for practice in rural and other settings with unique clinical demands, training of clinician educators, and retraining of subspecialists seeking to shift to generalist practice.

Ambulatory Care↗
PubMed1995

A physician workforce for the 21st century.

Medicine is entering an unprecedented era of provider abundance, including both physician and nonphysician providers. Over the next several decades, the projected number of primary care physicians will be more than adequate to meet national needs, although there is no assurance that any number of physicians will create an equitable distribution. At the same time, a growing surplus of specialists is projected. A balanced abundance in both primary care and specialty medicine will continue if approximately 33% of first-year residents ultimately practice primary care and 67% become specialists. In contrast, a shift to 50:50, as has been proposed by the Committee on Graduate Medical Education and others, will lead to a superabundance in primary care and a potential deficiency in specialty medicine later in the 21st century. Under either scenario, maintaining balance will be aided by those physicians with sufficient generalist skills to enable them to practice at the interface of primary care and specialty medicine, the domain of "middle care." The nation will be well served by educational policy that imparts such generalist expertise to medical students and that creates a workforce of highly skilled physicians capable of caring for patients in the technologically advanced clinical environment of the future.

Clinical Competence↗
PubMed1991

Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits.

Facilitated asthma-specialist care delivered by allergists was compared to generalist care on the rate of relapse of asthma emergency room (ER) visits and hospitalizations and on asthma control in a prospective, controlled study of San Diego Kaiser Health Plan members with asthma. Subjects with asthma between the ages of 6 and 59 years presenting for acute ER care for asthma were systematically assigned by alternating, consecutively, the day of their ER visit to receive either (1) facilitated referral to an asthma specialist within the allergy department and concomitant comprehensive ongoing asthma care (intervention group, n = 149) or (2) continued outpatient management from generalist physicians (control group, n = 160). The course of their asthma was evaluated blindly during the subsequent 6 months by review of medical records, initial and follow-up questionnaires, and spirometry. Compared to the control group, the intervention group noted (1) a 75% reduction in the number of, and percent of, subjects with asthma awakenings per night (p less than or equal to 0.0001), (2) an almost 50% reduction in asthma ER relapses (p = 0.017) resulting from a reduction in the frequency of multiple relapse (p = 0.005), and (3) a greater use of inhaled corticosteroids (p less than 0.00001) and cromolyn (p = 0.002). Thus, facilitated referral of subjects with asthma to specialists in asthma therapy after acute ER therapy appears to reduce asthma ER relapses and to improve asthma outcome.

Adult↗
PubMed1995

Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes.

OBJECTIVES: This study sought to assess the impact of generalist versus specialist direction on the pattern of care and outcome in patients admitted to the hospital for unstable angina. BACKGROUND: Physicians trained as internists or as cardiologists may have different approaches to treating patients with unstable angina. METHODS: We reviewed a prospectively collected cohort of patients discharged with a diagnosis-related group (DRG) diagnosis of unstable angina from William Beaumont Hospital, a large community-based hospital in southeast Michigan. Of 890 consecutive patients, 225 were treated by internists and 665 by cardiologists. We compared these two groups with respect to patterns of use of established pharmacotherapies for unstable angina, diagnostic testing and clinical outcome. RESULTS: Patients treated by internists less often had a previous cardiac history (53% vs. 80%, p < or = 0.0001). Internists were less likely to use aspirin (68% vs. 78%, p = 0.032), heparin (67% vs. 84%, p < or = 0.001) or beta-adrenergic blocking agents (18% vs. 30%, p < or = 0.004) in their initial management. Exercise tests were performed more frequently by internist-treated patients (37% vs. 22%, p < or = 0.001), but catheterization (27% vs. 61%, p < or = 0.0001) and angioplasty (7% vs. 40%, p < or = 0.0001) were utilized less frequently. The incidence of myocardial infarction was similar (11% vs. 9%) in the two groups, but the mortality rate tended to be higher (4.0% vs. 1.8%, p = 0.06) in the internist group. CONCLUSIONS: Patients with unstable angina treated by internists were less likely to receive effective medical therapy or revascularization procedures and experienced a trend to poorer outcome. This study does not support a positive gatekeeper role for generalists in the treatment of unstable angina.

Aged↗
PubMed2005

Echolocation, vocal learning, auditory localization and the relative size of the avian auditory midbrain nucleus (MLd).

The avian nucleus mesencephalicus lateralis, pars dorsalis (MLd) is an auditory midbrain nucleus that plays a significant role in a variety of acoustically mediated behaviours. We tested whether MLd is hypertrophied in species with auditory specializations: owls, the vocal learners and echolocaters. Using both conventional and phylogenetically corrected statistics, we find that the echolocating species have a marginally enlarged MLd, but it does not differ significantly from auditory generalists, such as pigeons, raptors and chickens. Similarly, all of the vocal learners tend to have relatively small MLds. Finally, MLd is significantly larger in owls compared to all other birds regardless of how the size of MLd is scaled. This enlargement is far more marked in asymmetrically eared owls than symmetrically eared owls. Variation in MLd size therefore appears to be correlated with some auditory specializations, but not others. Whether an auditory specialist possesses a hypertrophied MLd appears to be depend upon their hearing range and sensitivity as well as the ability to resolve small azimuthal and elevational angles when determining the location of a sound. As a result, the only group to possess a significantly large MLd consistently across our analyses is the owls. Unlike other birds surveyed, owls have a battery of peripheral and other central auditory system specializations that correlate well with their hearing abilities. The lack of differences among the generalists, vocal learners and echolocaters therefore reflects an overall similarity in hearing abilities, despite the specific life history requirements of each specialization and species. This correlation between the size of a neural structure and the sensitivity of a perceptual domain parallels a similar pattern in mammals.

Analysis of Variance↗
PubMed2006

Ploidy controls the success of mutators and nature of mutations during budding yeast evolution.

BACKGROUND: We used the budding yeast Saccharomyces cerevisiae to ask how elevated mutation rates affect the evolution of asexual eukaryotic populations. Mismatch repair defective and nonmutator strains were competed during adaptation to four laboratory environments (rich medium, low glucose, high salt, and a nonfermentable carbon source). RESULTS: In diploids, mutators have an advantage over nonmutators in all conditions, and mutators that win competitions are on average fitter than nonmutator winners. In contrast, haploid mutators have no advantage when competed against haploid nonmutators, and haploid mutator winners are less fit than nonmutator winners. The diploid mutator winners were all superior to their ancestors both in the condition they had adapted to, and in two of the other conditions. This phenotype was due to a mutation or class of mutations that confers a large growth advantage during the respiratory phase of yeast cultures that precedes stationary phase. This generalist mutation(s) was not selected in diploid nonmutator strains or in haploid strains, which adapt primarily by fixing specialist (condition-specific) mutations. In diploid mutators, such mutations also occur, and the majority accumulates after the fixation of the generalist mutation. CONCLUSIONS: We conclude that the advantage of mutators depends on ploidy and that diploid mutators can give rise to beneficial mutations that are inaccessible to nonmutators and haploid mutators.

Adaptation, Physiological↗
PubMed2005

Evolution of host specificity in fleas: is it directional and irreversible?

Evolutionary trends in the evolution of host specificity have been the focus of much discussion but little rigorous empirical testing. On the one hand, specialization is often presumed to lead irreversibly into evolutionary dead ends and little diversification; this would mean that generalists might evolve into specialists, but not vice versa. On the other hand, low host specificity may limit the risk of extinction and provide more immediate fitness benefits to parasites, such that selection may favour evolution toward a generalist strategy. Here, we test for directionality in the evolution of host specificity using a large data set and phylogenetic information on 297 species of fleas parasitic on small mammals. The analyses determined whether host specificity, measured both as the number of host species exploited and their taxonomic diversity, was related to clade rank of the flea species, or the number of branching events between an extant species and the root of the phylogenetic tree (i.e., the total path length from the root of the tree to the species). Based on regression analyses, we found positive relationships between the number of host species used and clade rank across all 297 species, as well as within one (Hystrichopsyllidae) of four large families and one of seven large genera investigated separately; in addition, we found a positive relationship between the taxonomic diversity of host species used and clade rank in another of the seven genera. These results suggest a slight evolutionary trend of decreasing host specificity. Using a much more conservative likelihood ratio test, however, a random walk, or null model, of evolution could not be discarded in favour of the directional trends in all cases mentioned above. Still, these results suggest that host specificity may have tended to decrease in many flea lineages, a process that could have been driven by the benefits of exploiting a wide range of host species.

Adaptation, Biological↗
PubMed2006

Deficiencies of cross-training between pediatrics and otolaryngology: a survey of specialists in Canada.

OBJECTIVE: Conditions relating to the ear, nose and throat are very frequent problems encountered by general pediatricians. Similarly, a major percentage of patients seen and operated on by the general otolaryngologist are of the pediatric age group. The pilot study demonstrated that pediatric program directors of both specialties in Canada have identified a deficiency of cross-training and desire the need for more cross-training. The aim of this study was to survey practicing physicians of both specialties for their input. METHODS: Surveys were sent to a large cross-section of pediatricians and otolaryngologists in Canada. They were asked to complete a questionnaire relating to their training experience, their desired training, important topics and general comments. Demographic data were collected including generalist versus sub-specialist, the year that residency was completed and country of training. Results were tabulated and analyzed. RESULTS: The response rate was high, being 70.6% and 76.2% for pediatricians and otolaryngologists, respectively. One hundred percent of pediatricians indicated that formal training by otolaryngologists was necessary, while 95% of otolaryngologists indicate a need for formal training by pediatricians during residency. Pediatricians desire more training using all three educational venues, namely lectures, clinics and rotations. While they are receiving lectures more often, they indicate that clinics are the most important mode of education. Otolaryngologists desire more formal training by pediatricians in the areas of lectures and clinics. They indicate the most important mode of education is lectures. There was no significant difference between generalists and sub-specialists or based on country of training for either group. There is some indication, in both specialties, of an increase of cross-training occurring within the past five years. CONCLUSIONS: This study has shown that there is a perceived deficiency of cross-training between the two specialties. Both pediatricians and otolaryngologists have indicated that they need more formal cross-training. This is a very important area to address, as this study relates directly to the optimum health of children in Canada and worldwide.

Canada↗
PubMed2006

Eating disorder nutrition counseling: strategies and education needs of English-speaking dietitians in Canada.

The purpose of this study was to profile nutrition counseling strategies for eating disorders that English-speaking Canadian registered dietitians (RDs) use and to explore their educational needs in this area. A cross-sectional survey consisting of open- and closed-ended questions on nutrition counseling strategies was developed and administered via mail. Types of strategies included assessment, rapport-building, educational, and behavior-change strategies. Sixty-five of the 116 eligible RDs who were members of the Dietitians of Canada Eating Disorder Network responded to the survey. Descriptive statistics, chi(2), and Spearman correlation statistics were used. P values less than 0.05 were considered significant. Canadian RDs used strategies that were familiar and strategies they considered useful. Content-oriented or "doing" strategies were used more often than strategies that involved some process-oriented or "thinking" strategies. Reading and intuition were the most frequently reported learning routes. Seventy-one percent of respondents were dissatisfied with the educational opportunities available to RDs in this area in Canada. In Canada, both generalist RDs and specialist eating disorders RDs work with clients with eating disorders. In the absence of a formal nutrition counseling education program, there seems to be a reliance on informal learning routes such as reading or intuition, which may be suboptimal. To optimize eating disorders nutrition practice in Canada, formal coordinated programming that accounts for the educational needs of specialist RDs as well as generalist RDs is needed.

Anorexia Nervosa↗
PubMed2005

Imitation: is cognitive neuroscience solving the correspondence problem?

Imitation poses a unique problem: how does the imitator know what pattern of motor activation will make their action look like that of the model? Specialist theories suggest that this correspondence problem has a unique solution; there are functional and neurological mechanisms dedicated to controlling imitation. Generalist theories propose that the problem is solved by general mechanisms of associative learning and action control. Recent research in cognitive neuroscience, stimulated by the discovery of mirror neurons, supports generalist solutions. Imitation is based on the automatic activation of motor representations by movement observation. These externally triggered motor representations are then used to reproduce the observed behaviour. This imitative capacity depends on learned perceptual-motor links. Finally, mechanisms distinguishing self from other are implicated in the inhibition of imitative behaviour.

Animals↗
PubMed2004

Dispersal and the evolution of specialisation in a two-habitat type metapopulation.

Metapopulation theory for the evolution of specialisation is virtually absent. In this article, therefore, we study a metapopulation model for consumers with a fitness trade-off between two habitats. We focus on effects of habitat abundance, dispersal rate and trade-off strength on the evolution of specialisation under two types of trade-off. Adaptation affects either the intrinsic growth rates r or the carrying capacities K. Depending on dispersal rate and trade-off strength, evolution can result in one generalist, one specialist or two specialist types. Higher dispersal rate and a weaker trade-off favour the evolution of a generalist, for both trade-off structures. However, we also find differences between the two trade-off structures. Our results are qualitatively similar to analyses of two-patch models, suggesting that insights from such simpler models can be extrapolated to metapopulation models. Additional effects, however, occur because in classical metapopulations patch lifetime depends on extinction rate. Counterintuitively, this favours the evolution of specialisation when the trade-off affects r.

Adaptation, Physiological↗
PubMed2004

A comparison of survival of teeth following endodontic treatment performed by general dentists or by specialists.

OBJECTIVE: A chart review was performed at 3 private general practices in different regions of Alabama to compare success of endodontic treatment provided by specialists versus generalists. STUDY DESIGN: To qualify for the study the general dentists had to perform some endodontic treatment and to refer some to endodontists. Success was defined as the treated tooth being present at 5 years after the date of treatment initiation. This criterion, was chosen because of its unequivocal categorization of results. Calibrated dentists reviewed over 3,000 charts. RESULTS: 350 met the inclusion criteria. 195 teeth were treated by generalists, with an 89.7% success rate. 155 teeth were treated by endodontists, with a 98.1% success rate. CONCLUSION: In this limited survey, endodontic treatment by specialists was significantly more successful.

Dental Restoration Failure↗
PubMed1996

Strategic business planning for internal medicine.

The internal medicine generalist is at market risk with expansion of managed care. The cottage industry of Academic Departments of internal medicine should apply more business tools to the internal medicine business problem. A strength, weakness, opportunity, threat (SWOT) analysis demonstrates high vulnerability to the internal medicine generalist initiative. Recommitment to the professional values of internal medicine and enhanced focus on the master clinician as the competitive core competency of internal medicine will be necessary to retain image and market share.

Economic Competition↗
PubMed1997

Primary care by obstetricians and gynecologists: attitudes of the members of The South Atlantic Association of Obstetricians and Gynecologists.

OBJECTIVE: Our purpose was to determine the extent of primary care delivered by obstetrician-gynecologists and compare practice patterns with published primary care and preventive service guidelines. STUDY DESIGN: All 277 active fellows of The South Atlantic Association of Obstetricians and Gynecologists were mailed a self-administered questionnaire. The type of primary care offered by these physicians and their attitudes about the training of residents in obstetrics and gynecology were surveyed. Physicians were categorized as generalists or specialists on the basis of the completion of a fellowship program. Descriptive statistics and chi 2 analysis were used for statistical analysis. RESULTS: Completed surveys were returned by 82% of the fellows. The majority of the respondents perceived their practice as specialty care for women. Generalists offered recommended screening services to women of all ages with greater frequency than the specialists did (p = 0.05). Both groups did not provide care for the chronic medical illnesses most commonly seen in a primary care practice. The respondents favored more residency training in those common acute illnesses frequently encountered in a primary care setting. CONCLUSIONS: Obstetrician-gynecologists in The South Atlantic Association of Obstetricians and Gynecologists selectively practice primary care. These physicians did not support caring for chronic medical problems frequently treated in an ambulatory care practice.

Attitude of Health Personnel↗
PubMed2001

Measuring medical students' experience with surgical problems and procedures.

BACKGROUND: Measuring medical students' experience on their surgical clerkship rotations to assess the adequacy of the breadth of exposure is essential for producing generalist clinicians. METHODS: A Surgical Clinical Checklist was developed by surveying the surgical faculty for those surgical problems and procedures that every generalist physician should experience. The checklist was then distributed to 48 consecutive third-year medical students for completion during their core clerkship in surgery. RESULTS: Students reported encounters with surgical procedures more frequently than with surgical problems (64.3% of procedures versus 21.9% of problems were encountered by 80% of respondents). Students actively participated as often as they reported passive observation alone. Students assigned to two different teaching sites encountered similar numbers of items at each site although the distribution of individual items was different. CONCLUSIONS: The Surgical Clinical Checklist provides a valuable measurement tool to assess student experiences on their surgical clerkship and can be used to direct future teaching initiatives.

Clinical Clerkship↗
PubMed1997

Practicing primary care physicians' perspectives on the junior surgical clerkship.

PURPOSE: Changing emphasis on educating generalist physicians prompted us to survey practicing primary care physicians to determine their perception of the lecture content and clinical skills required of students in our third-year surgical clerkship. METHODS: A 72-item questionnaire was developed. Respondents were asked to evaluate the relative importance of lecture topics and clinical skills on a 5-point Likert-type scale. Respondents were also asked about their medical practice and demographic information. Primary care physicians were randomly selected from among those registered in our state's medical association. RESULTS: Nearly 70% of physicians in the sample responded. Although there were significant differences in responses among the primary care physicians surveyed, virtually all indicated that faculty should teach pathways in surgical management with emphasis on when to refer the patient to a surgeon. CONCLUSIONS: The changing health care climate necessitates a closer examination of undergraduate surgical curricula with attention to the educational needs of the generalist physician.

Attitude of Health Personnel↗
PubMed2003

Towards a learning organization: the introduction of a client-centered team-based organization in administrative surveying work.

Within administrative surveying work in Sweden, a transition to a client-centered team-based organization was made during 1998. The aim of this study was to describe the employees' perceptions and expectations of job and organizational practices when working as a generalist in a client-centered team-based organization; job and organizational practices and well-being and effectiveness measures were examined when introducing a team-based organization. Interventions such as courses in how to cope with the role of a generalist, how to increase service to clients, education in technology, law and economics, as well as computer information support, were ongoing at the time of the study. The Team Work Profile and QPS Nordic questionnaires were used. All the surveyors in five regions in Sweden participated, in total 640 surveyors. The transition to a client-centered team-based organization was expected to improve job control and job content but at the same time lead to impairments in job climate and group cohesion. Distress was associated with negative future expectations of the organization. High job control and group cohesion were the central contributors towards growth in personal competence and social effectiveness of teamwork. Both internal and external client-related activities of team and organization were in focus during the transition.

Cooperative Behavior↗
PubMed1998

Biodiversity of parasites in a freshwater environment with respect to pollution: metazoan parasites of chub (Leuciscus cephalus L.) as a model for statistical evaluation.

This paper represents an attempt to evaluate the environmental indicative potential of the biodiversity of monogenean parasites using hierarchically structured species-abundance data. A logical set of statistical methods integrating standard diversity indices, a novel approach to quantitative analysis of cumulative species-abundance curves and species-abundance models was applied for this purpose. Applicability of biodiversity measures was demonstrated using experimental data from a 1-year study on the ecology of metazoan parasites of chub (Leuciscus cephalus) in one polluted and one control site in the Morava river, Czech Republic. Analyses at the component community level revealed a significant decrease in the number of parasite species with a more equal distribution of their abundances in the polluted site compared with the control site. In order to reach a better understanding of the changes, diversity of Monogenea as a dominant part of the community was further examined within categories of species created according to: (1) specificity of infection (specialists and generalists), (2) monogenean genera (Dactylogyrus, Gyrodactylus and Paradiplozoon) and (3) inhabited guilds (skin + fins, gills). Assemblages of specialists in the polluted site exhibited a significantly reduced species richness and unequal distribution of abundances. The opposite pattern was observed in the case of generalists. The influence of pollution was also reflected by the distribution of species abundances within communities of Dactylogyrus and Paradiplozoon, while no significant shift was identified in the genus Gyrodactylus.

Animals↗