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PubMed2005

Baccalaureate-linked oncology nursing education: McMaster University's Paediatric and Adult Oncology Nursing Program.

For new nursing graduates prepared as generalists, the transition from student to graduate and from new generalist graduate to experienced specialized nurse can be very anxiety-provoking. This paper discusses one program, the Oncology Nursing Program, McMaster University, designed for nurses working along the cancer continuum. Proposed by oncology nurses seeking baccalaureate-linked specialty education, the year-long program has now been in existence for 10 years. A cadre of nearly 200 graduates affirm that specialized education influences direct patient care, health care team membership, professional and personal development.

Adult↗
PubMed1992

Alternative pathways for training the general internist and the medical subspecialist.

Considerable attention is being directed from within the discipline of internal medicine to a perceived need for changes in the curriculum for postgraduate training of the internist. Much of this attention has been focused on the training required to properly prepare the general internist for the evolving system of health care. A proposal is presented to change the pattern of training of both the general internist and the medical subspecialist. After 2 years of core training, the general internist would enter 2 additional years of training that would include new material and additional experience in areas such as ambulatory and continuity care. After the core experience, the subspecialist would begin training in the subspecialty. The general internist would be certified as such, and the subspecialist would be certified only in the subspecialty. The proposal is based on the assumptions that 1) more general physicians are needed to meet the nation's health care needs; 2) more time will be required to properly train the general internist; 3) all of the additional and expanded training experiences for the generalist are not essential for training the subspecialist; and 4) the generalists of the future will not come from the ranks of subspecialists. The training needs of the general internist and the subspecialist should be viewed as separate, and curriculum changes should be considered without the restrictions of current patterns of training.

Curriculum↗
PubMed1997

The generalist/cardiovascular specialist: a proposal for a new training track.

The economic forces that are reshaping the delivery of health care in the United States have led to intense examination of the appropriate roles for specialists and generalists. Resolving this issue has profound implications for the future of U.S. health care and for the economic health of academic training centers and individual physicians. The issues are particularly intense in cardiovascular care, a field that has had dramatic success in the application of new diagnostic and therapeutic technology and rapid growth in specialist practitioners but is now under pressure to shrink its ranks. A new generalist/cardiovascular specialist training track and a parallel reduction in the number of standard fellowship training positions in cardiovascular disease may be a partial solution. The first 2 years of the proposed 5-year program would consist of training in internal medicine, the final 2 would consist of training in cardiovascular disease, and the middle year would be a flexible combination of the two. Graduates would be Board eligible in internal medicine but would have enhanced competency in cardiovascular disease. This plan may improve the balance between generalists and specialists, improve the quality of primary and specialized cardiovascular care, and strengthen departments of medicine and academic training centers while facing new economic realities.

Cardiology↗
PubMed2001

General internal medicine at the crossroads of prosperity and despair: caring for patients with chronic diseases in an aging society.

During the past quarter century, general internal medicine has emerged as a vital discipline. In the realm of patient care, it is the integrating discipline par excellence. Ironically, as general internists face the challenge of integrating advances of dizzying speed and complexity, and as their clinical practice becomes increasingly effective, it has become much more difficult for them to earn a living. General internists find themselves at the crossroads of prosperity and despair. Although general medicine research leads the research agenda in many departments of medicine, it is particularly vulnerable. The necessary multidisciplinary "programmatic" infrastructure is expensive, and results often take many years to obtain, particularly in the study of chronic disease. The educational environment in many institutions is particularly difficult for general medicine, both because the current emphasis on technical skills obscures patients' and learners' real needs and because complex patients on general medicine services are now so ill and their turnover so rapid. General internal medicine and geriatrics are synergistic, especially in today's marketplace. A focus on geriatric medicine could help general medicine continue to flourish. General internists are ideally suited to the integrated care of elderly patients with multiple problems, research opportunities are enormous in the geriatric population, and the teaching of geriatrics requires a high level of generalist skills. Problems that plague current generalist practice have unique significance to older patients. Organizations that represent general internists would do well to join forces with many other advocacy groups, especially those representing the interests of elderly patients and geriatric medicine.

Chronic Disease↗
PubMed2004

The effect of a 13-hour curriculum to improve residents' teaching skills: a randomized trial.

BACKGROUND: Although resident physicians often teach, few trials have tested interventions to improve residents' teaching skills. A pilot trial in 2001-2002 found that 13 trained resident teachers taught better than did untrained control residents. OBJECTIVE: To determine whether a longitudinal residents-as-teachers curriculum improves residents' teaching skills. DESIGN: Randomized, controlled trial from May 2001 to February 2002 (pilot trial) and March 2002 to April 2003. SETTING: 4 generalist residencies affiliated with an urban academic medical center. PARTICIPANTS: 62 second-year residents: 23 in the 2001-2002 pilot trial and 39 more in 2002-2003; 27 of the 39 participants were medicine residents required to learn teaching skills. INTERVENTION: A 13-hour curriculum in which residents practiced teaching and received feedback during 1-hour small-group sessions taught twice monthly for 6 months. MEASUREMENTS: A 3.5-hour, 8-station, objective structured teaching examination that was enacted and rated by 50 medical students before and after the intervention. Two trained, blinded raters independently assessed each station (inter-rater reliability, 0.75). RESULTS: In the combined results for 2001-2003, the intervention group (n = 33) and control group (n = 29) were similar in sex, specialty, and academic performance. On a 1 to 5 Likert scale, intervention residents outscored controls on overall improvement score (post-test-pretest difference, 0.74 vs. 0.07; difference between intervention and control groups, 0.68 [95% CI, 0.55 to 0.81]; P < 0.001) by a magnitude of 2.8 standard deviations and on all 8 individual stations. The intervention residents improved 28.5% overall, whereas the scores of control residents did not increase significantly (2.7%). In 2002-2003, 19 intervention residents similarly outscored 19 controls (post-test-pretest difference, 0.83 vs. 0.14; difference between intervention and control groups, 0.69 [CI, 0.53 to 0.84]; P < 0.001). Twenty-seven medicine residents required to learn teaching skills achieved scores similar to those of volunteers. LIMITATIONS: The study was conducted at a single institution. No "real life" assessment with which to compare the results of the objective structured teaching examination was available. CONCLUSIONS: Generalist residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum consistently showed improved teaching skills, as judged by medical student raters. Residents required to participate improved as much as volunteers did.

Curriculum↗
PubMed1997

An osteopathic prescription for medical education reform: Part 1. Curriculum and infrastructure.

Medical education has not kept pace with the evolving healthcare system. Criticism from industry and policy observers focuses on four major areas requiring reform: the curriculum, the fragmented educational infrastructure, the specialist-to-generalist mix, and the alienation from community and public health. The dominance of managed care organizations in the delivery and financing of healthcare is forcing a new set of physician competencies to the fore and changing projections of physician manpower and specialty needs. The authors address the four major criticisms from a uniquely osteopathic point-of-view. In this first of two articles, the authors describe the evolving osteopathic medical education model, and then employ a medical analogy to diagnose the causes of and propose treatments for curricular issues and infrastructure fragmentation. In the second article of the pair, they explore the causes of and propose strategies to address the generalist-to-specialist imbalance and the alienation of medicine from community and public health; the article also explores the role of technology in support of reform. In each article, the authors propose treatments to correct the problems in the osteopathic medical education model, and conclude that the profession is well-positioned to lead medical education reform.

Curriculum↗
PubMed1995

From managing access to managing care: the impact of primary care on health care delivery organizations.

Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article.

Health Services Accessibility↗
PubMedDate not supplied

[Benign prostatic hyperplasia. Guidelines and recommendations in urological clinical practice].

After reviewing the clinical, diagnostic and therapeutic attitudes related to benign prostatic hyperplasia, the authors present guidelines for generalists in what concerns practical attitudes and when and how to refer their patients to the urologist. Based on the criteria presented, generalists must refer their patients to a urologist in the presence of mild or severe symptoms, ages below 50, diabetes or neurological perturbations, dysfunctional voiding, palpable bladder, palpable nodule or a diffusely hardened or asymmetric gland revealed by digital rectal examination, haematuria, urinary tract infection, renal impairment or PSA above 4 ng/ml in patients under 70 years of age.

Adult↗
PubMed1999

Defining responsibility for screening.

Patients commonly receive medical care from multiple providers and confusion as to who is responsible for cancer screening undoubtedly contributes to inadequate recommendations. Effective screening requires successful implementation of a series of steps that begin with the initial discussion of a screening test and proceed through obtaining results and instituting appropriate follow-up. Clear definition of generalist and specialist physician roles are necessary to optimally screen the public. This article explores the differences in how generalists and specialists approach screening, describes models of care that facilitate shared responsibility for screening, and suggests strategies on how to improve communication between physicians to maximize screening performance.

Attitude of Health Personnel↗
PubMed1999

Rural hospitals in New Zealand.

AIM: To produce a list of New Zealand rural hospitals, including information on acute bed numbers, population served, average driving time to base hospital, and number and payment of rural hospital doctors. METHODS: Information about rural hospitals was obtained from local doctors and/or administrators, and reflected conditions at June 15, 1998. A 'rural hospital' was defined as a facility with no resident medical specialists, where acutely ill patients are admitted and cared for solely by generalist doctors, either general practitioners or medical officers of special scale. RESULTS: Varying definitions for acute 'facilities' and 'beds' made analysis difficult. There were a total of 36 'rural hospitals' in New Zealand at June 15, 1998 containing 293 acute beds and serving a population of about 340000. Patient care was provided by a total of 131 generalists (general practitioners or medical officers of special scale) equivalent to 40 full-time rural hospital doctors. CONCLUSIONS: Approximately 10% of the New Zealand population are served by rural hospitals. Discrepancies exist between the list of rural hospitals provided in this study and that provided by the Government's recent 'Hospital Services Plan'.

Health Services Research↗
PubMed1999

Helminth communities in Audouin's gulls, Larus audouinii from Chafarinas Islands (western Mediterranean).

A survey of intestinal helminth communities of Audouin's gulls Larus audouinii, from their breeding colonies in Chafarinas Islands, western Mediterranean, Spain was conducted to determine the abundance and species diversity of intestinal parasites of these birds. The sample of 58 gulls harbored intestinal helminth infracommunities composed of species that are gull generalists, including the digeneans Cardiocephalus longicollis, Knipowitschiatrema nicolai, Condylocotyla pilodora, and Aporchis massiliensis, and the cestode Tetrabothrius cylindraceus. Two nematodes are waterfowl generalists (Cosmocephalus obvelatus and Paracuaria adunca), whereas the digenean Acanthotrema armata is an Audouin's gull specialist. The relative high values of species richness and diversity of the helminth infracommunities are comparable to those of other gulls (Larus philadelphia, Larus canus), probably reflecting the specialized, nonselective fish diet of L. audouinii.

Animals↗
PubMedDate not supplied

[Education and role of the toxicologist].

Toxicology covers a very large scientific area, needing specialists in the main basic disciplines involved, and generalists with a large and practical overview. Academic education, consequently, should take this necessity into account. This education is presently satisfactory in France, even if some adjustments are necessary, for the specialists but is inadequate for the generalists, whereas an important need exists in industry. It should be emphasized that toxicology is a profession and consequently practical experience is essential, as well as continuing education. In view of this situation, an evaluation of toxicologists in the course of their professional activities is necessary. In the USA, this evaluation is devolved to the American Board of Toxicology and in Europe to the Eurotox Accreditation. In conclusion of the Round Table, 8 recommendations are proposed.

Accreditation↗
PubMed2000

[Difficulties with the implementation and institutional stakes in the continuing education of private physicians].

The Formation Medical Continue (FMC) is a continuing education programme for private practice doctors (generalists and specialists), and was established in the legislation of April 1996. In analysing the stages of the policy's introduction, an attempt was made to understand the difficulties encountered in its implementation. Using a semi-directive questionnaire, the opinions concerning the policy were collected from the different actors in the process: professionals, social welfare organisations, government agencies and health organisations. The analysis of their perceptions was complemented by an analysis of historical data and a review of the literature. The greatest difficulties with implementation related to the interactions among the stakeholders: the "game" of the medical unions, among themselves and with social security and government agencies; the under-representation of the medical profession, exacerbated by its divisions and the split between generalists and specialists; the indecision of government agencies, leaving the stakeholders waiting; the "game" of the social security funds, which act as if the principle of "mutualisation" of FMC funds can be by-passed. Conflicts of interest regarding the FMC have "crystallised" among the different stakeholders, as well as within the medical corpus. These conflicts relate in particular to the creation of the memorandum agreement and to the definition of the relationship with the pharmaceutical industry.

Attitude of Health Personnel↗
PubMed2001

The domain of family practice: scope, role, and function.

The family physician is the physician generalist who takes professional responsibility for the comprehensive care of unselected patients with undifferentiated problems and who is committed to the person regardless of age, gender, illness, or organ system. The clinical specialty of family practice is patient centered, evidence based,family focused, and problem oriented. Family physicians acquire and maintain a broad array of competencies that depend on the needs of the patients and communities they serve. The scope of their practice is not defined by diagnoses or procedures but by human needs. Family physicians do not treat diseases; they take care of people. Nodal points in the family life cycle, such as birth, serious illness, and the end of life, deserve special attention. Family physicians are expert at managing common complaints, recognizing important diseases, uncovering hidden conditions, and managing most acute and chronic illnesses. They emphasize health promotion and disease prevention. Their knowledge, skills, and attitudes target community practice, current science, and continuous quality improvement. Family practice has a distinct clinical approach that requires special skills to identify concerns, focus issues, negotiate plans, and help solve problems. The recognition, integration, and prioritization of multiple concerns and the synthesis of solutions are critical clinical competencies. The variety of human needs require targeting the clinical process, sharing responsibility, and managing uncertainty. Focus on the person requires refined abilities to observe, communicate, understand, and care. Commitment to patients and populations involves activism and advocacy. Family medicine can lead in redefining what it means to be a professional, a physician, and a generalist.

Clinical Competence↗
PubMed2001

Developing the knowledge base of family practice.

Borrowed and adapted knowledge is insufficient to optimize the potential of a comprehensive, integrative, relationship-centered generalist approach to improve the health of individuals, families, and communities. The knowledge base for family practice must be expanded by integrating multiple ways of knowing. This involves (1) self-reflective practice by clinicians, (2) involving the patient voice in generating research questions and interpreting data, (3) inquiry into the systems affecting health care, and (4) investigation of disease phenomena and treatment effects in patients over time. A multimethod, transdisciplinary, participatory approach is needed to create knowledge that retains connections with its meaning and context and therefore is readily translated into practice. This research integrates quantitative and qualitative traditions and involves the active participation of both clinicians and patients. The generation of relevant knowledge should be supported through (a) developing a culture of reflective practice among clinicians, (b) expanding the infrastructure for practice-based research, (c) developing a multimethod, transdisciplinary, participatory research paradigm, (d) longitudinal study of the process and outcomes of broad, integrative, relationship-centered care, and (e) incorporating pursuit of new knowledge as a central feature of training programs and policy. The time has come for the generalist disciplines to commit to the generation of new knowledge based on the needs of patients, families, and communities for relationship-centered, integrated, prioritized health care. Development of a culture of learning and inquiry, and the necessary research methods and skills will require a long-term commitment, creation of partnerships, and a focus on core principles by individuals and organizations.

Algorithms↗
PubMedDate not supplied

[Prostatic benign hyperplasia].

After reviewing the clinical, diagnostic and therapeutic attitude related to Benign Prostatic Hyperplasia, the authors present the guidelines for Generalists, in terms of practical handling and when and how to refer their patients to the Urology consultation. Based on the criteria presented, Generalists must refer their patients to the Urology consultation in the presence of mild or severe symptoms, ages below 50 years, diabetes or neurological disturbances, disturbed voiding, palpable bladder, palpable nodule or a diffusely hardened or asymmetric gland revealed by digital rectal examination, hematuria, urinary tract infection, renal impairment or PSA above 4 nglml in patients aged below 70 years.

Algorithms↗
PubMedDate not supplied

The infusion nurse and patient complication rates of peripheral-short catheters. A prospective evaluation.

The objective of this study was to compare catheter-related complication rates in patients who had infusion devices placed by infusion nurses with complication rates in patients who had devices placed by generalist nurses. The data demonstrated that peripheral infusion devices placed by infusion nurses exhibited a statistically significant lower rate of leakage, phlebitis, and infiltration complications and remained in the vein significantly longer than those placed by generalist nurses. However, significance was not achieved with pain complication rates between the two groups. The implications of these outcomes for staff development and quality of patient care are discussed.

Adult↗
PubMed2001

Beyond the essentials. Teaching critical care to undergraduate and graduate students in nursing.

With more new graduates entering the critical care setting and with the evolving role of the advanced practice nurse, teaching critical care content to students in nursing is a challenge for faculty. The burden to educate undergraduate novices and advanced practice nurses to care for the complex critically ill patient is costly for health care agencies. To help prepare the generalist to enter a world of specialty, precepted critical care experiences, faculty/critical care nurse collaboration, critical care simulation experiences, a computerized entry-level critical care examination, and a National Fellowship critical care registry are suggested. Teaching strategies for the advanced practice nurse beyond the American Association of Colleges of Nursing's "essentials" document include consideration of expanded science education, simulation for psychomotor skills and diagnostic reasoning cases, and interdisciplinary education for bioethics and business courses. Although such controversies as preparing the generalist for a specialty and the availability of preceptors continue to be debated, the future of critical care education is exciting and challenging. As technology continues to evolve, and the consumer in a market-driven society becomes more involved and inquisitive, the need for caring remains. That is the joy of teaching critical care nursing.

Critical Care↗