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PubMed2002

Effect of a patient care partnership project on cost and quality of care at an academic teaching hospital.

BACKGROUND: In 1998, the Patient Care Partnership Project was conducted by general internal medicine physicians and hospital administration in an academic health care center. The project was designed to optimize cost, quality, and service results to inpatients. METHODS: The project focused on improved communication among physicians, a nurse discharge planner, and hospital administration regarding appropriate resource utilization. The outcomes were average cost per inpatient, length of hospital stay, 30-day readmission rates, mortality rates, and resident and patient satisfaction. Comparisons were made with three control groups. RESULTS: The postintervention generalist-staffed services showed significant reductions in average costs per patient and length of stay. These parameters increased in the specialist group from 1997 to 1998. Readmission rates remained stable, and mortality rates actually decreased. Patient and resident satisfaction remained unchanged. CONCLUSIONS: A collaborative effort between generalists and hospital administration led to a significant improvement in resource utilization compared with the three control groups, with no compromise in quality outcomes.

Analysis of Variance↗

PubMed2002

Aphid prey suitability as environmental effect on Adalia bipunctata reproduction.

Secondary plant metabolites (allelochemicals) play a major role in plant-insect interactions. Glucosinolates (GLS) and their degradation products from Brassica species are attractants and feeding stimulants for Brassicaceae specialist insects but are generally repellent and toxic for generalist herbivores. The impact of these compounds on crucifer specialist insects are well known but their effect on generalist predators is still not well documented. Prey host plant influence on reproduction of an aphidophagous beneficial, the two spot ladybird, was determined using the cabbage aphid, Brevicoryne brassicae reared on a crucifer plant, namely Brassica napus containing low GLS levels. As ladybird developmental and reproductive parameters were already shown to be strongly affected by the allelochemical presence in its preys, the unsuitable aphid and host plant combination was only momentary used to feed the A. bipunctata adults. A strong impact of the diet was observed on the beetle fecundity and the emerging offspring. Changing B. brassicae aphid to a suitable prey slowly improved the temporary negative effect of the former diet. These results enhance the food environmental effect and the importance of tritrophic relations in pest management strategies by predators. Indeed, more than the choice of the beneficial species, the prey host plant has a major influence on the potential efficacy of biological agent to control herbivore species such as aphids.

Animals↗

PubMed2003

Evaluating health plan quality 3: survey measurement properties.

OBJECTIVE: To assess the measurement and scaling properties of survey items designed to measure health plan quality from a physician's perspective. STUDY DESIGN: Prospective survey design with multivariate regression analysis. METHODS: Data were from 3798 physicians representing 23 health plans in 5 regions: Florida, New York, Colorado, Pennsylvania, and Washington. Scale reliability was assessed by using the Cronbach alpha. Generalist and specialist scales were compared with structural equation modeling. Multivariate analysis was used to examine internal validity by testing theoretically based hypotheses. RESULTS: Scales constructed from the data were reliable, were stable across both generalist and specialist physicians, and demonstrated construct validity. Hypotheses about the relationship between physician experiences with a health plan and physician recommendations of the plan were confirmed, supporting construct validity. CONCLUSION: The items on the survey instrument can be used with confidence to measure health plan quality from a physician perspective.

Attitude of Health Personnel↗

PubMed2001

Overcoming the top 10 tracheotomy self-care learning barriers.

Multispecialty inpatient units are the norm in today's acute care settings. Since few units have the luxury of seasoned otorhinolaryngology (ORL) nurses, care of the postoperative patient with a tracheotomy, including discharge teaching and planning are left to the generalists. Generalist nurses and new ORL nurses may find themselves experiencing fear and anxiety along with the tracheotomy patients they care for and teach. Experienced ORL nurses are continually challenged to find ways to share their expertise with patients and less experienced nurses in effective ways. This article presents a unique approach to preparing nurses to teach self-tracheotomy care to their patients. Medical-surgical staff nurses attended a 90-minute inservice program presenting actual clinical scenarios of temporarily learning-impaired patients with tracheotomies, and were asked to role play effective interventions. The program content is designed to address the reluctance of inexperienced, busy nurses to confront learning barriers and motivate patients to accomplish early postoperative involvement in tracheotomy self care. The widespread nature of the challenges faced by nurses and patients regarding tracheotomy care has been confirmed by discussions with colleagues on a national level. It has been confirmed further by the first author's clinical experiences in a wide variety of health care settings. Recommended nursing actions and responses to learning barriers presented here are based on expert opinion and clinical experience.

Activities of Daily Living↗

PubMed2003

Information needs of residents during inpatient and outpatient rotations: identifying effective personal digital assistant applications.

Last year, we reported (2002 AMIA Proceedings, p 971) on how medical school residents report on their use of personal digital assistants (PDA) or hand held devices. We first surveyed 88 residents in six residency programs representing both generalist and specialist practices (Family Medicine, Internal Medicine, Neurology, Pediatrics, Radiology, and Surgery. Following our survey, we contacted some of these same residents for follow-up advantages and disadvantages of specific software applications, and what information residents would like to have on their PDAs. Our survey and interview results included several specific advantages and disadvantages of PDA usage by residents. Advantages included: (1) many residents readily adapted the personal organizers (calendars. address books, to-do lists) to help keep track of their clinical tasks, and keeping in touch with patients, (2) commercial medical references (such as ePocrates) are used most by the surveyed residents to answer immediate medical questions. Perceived drawbacks include: (1) calculators and patient trackers that were not clearly able to be tailored to residents' needs, e.g., to limit and modify types of calculations to just those actually used, (2) physical size (both too small a display size, and too bulky overall), and (3) several residents mentioned a concern of becoming too dependent on one source of information, a source that was viewed as being too easy to lose or break. Three broad patterns emerged. First, residents in all seven of our surveyed practices use PDAs and most surveyed residents use them on a daily basis; we conclude that PDAs are being widely used across the spectrum of generalist to specialty practices, regardless of whether a residency program specifically encourages PDA usage. Second, security and HIPAA compliance issues need to be addressed, in part by resident education about archiving PDA files. Lastly, PDAs may become even more widely used if clinical data specific to an individual resident can easily and securely be maintained on PDAs. Design of Current Studies Our current study builds on the above perceived needs: we will follow residents during portions of a clinical day. Preliminary observations in three clinical areas (Medical Intensive Care Unit (MICU), General Medicine Outpatient, and Family Medicine Outpatient) confirm the conclusions of our previous study. PDAs are used for: (1) medical references (e.g., five minute clinical consult, Infotriever) (2) pharmaceutical information (such as ePocrates), and (3) professional organization (calendar, address book). Our intention in this new study is to identify the overall flow of information and how PDAs might improve the information flow in clinical settings. We choose to observe residents in both inpatient and outpatient clinics. We anticipate that PDAs will have different uses in these two settings; preliminary observations in one outpatient clinic (Family Medicine) suggests that PDAs are used during the doctor - patient interaction, specifically to suggest the importance of smoking cessation. Preliminary observations in an inpatient clinical setting (the MICU) suggest that PDAs are primarily used outside of patient rooms, e.g. to make medical calculations and to obtain diagnostic procedures. We plan to observe residents during various parts of their days in order to develop a detailed understanding of what information sources (e.g., consultations, computer reports, paper charts) are available at different times and which sources are frequently used. This information will help us develop a pocket-sized, paper-based checksheet that the residents carry with them. The checksheet will help us identify which information sources are used, at various times and frequencies. Interviews with the residents using these checksheets should provide additional details of how utility of the resource, disadvantages of the resource, etc. Specific Goals The goals of our current study include: (1) direct observations of residents PDA usage to determine how this compares to our previous results (above), ts (above), (2) determine if PDA usage varies between outpatient and inpatient clinics, (3) determine how different information sources are used in these clinics. Our long range goal includes considering how PDAs might improve the information gathering processes by identifying useful PDA applications, along with user interfaces residents find intuitive.

Computers, Handheld↗

PubMedDate not supplied

Impact of hepatologists to extend survival of hepatocellular carcinoma patients with cirrhosis: a comparison with non-hepatologists.

BACKGROUND/AIMS: Whether or not generalists and specialist physicians can make an appropriate adaptation of their practice patterns when caring for their patients currently remains a matter of debate. The present study was undertaken to explore whether the clinical characteristics of hepatocellular carcinoma at its time of detection, the initial treatment options and the survival vary between patients with hepatocellular carcinoma associated with cirrhosis who were treated by hepatologists and those who were treated by non-hepatologists. METHODOLOGY: A retrospective study with 626 patients with hepatocellular carcinoma associated with cirrhosis was performed. The patients were stratified into three groups as follows; 1) a hepatologist group: 280 patients followed up and treated consistently by hepatologists, 2) a non-hepatologist group: 126 patients followed up and treated consistently by non-hepatologists, and 3) the other group: 220 patients either followed up by hepatologists and treated by non-hepatologists, or vice versa, or those identified to have tumors incidentally without any follow-up. To confirm the clear difference between generalists and specialists, the gender ratio, age, hepatitis B and C virus markers, serum alpha-fetoprotein level, tumor size, the number of tumors, Child's grade, portal thrombosis at the initial detection, the types of follow-up until the initial detection of hepatocellular carcinoma, the initial treatments chosen, and survival were compared between the hepatologist group and the non-hepatologist group. RESULTS: There were no statistically significant differences between the two groups with respect to gender ratio, age, hepatitis virus markers and the alpha-fetoprotein level. However, the tumor size, the number of tumors, Child's grade and portal thrombosis at the initial detection were more advanced in the non-hepatologist group, which was most likely due to the poorer follow-up until the detection of hepatocellular carcinoma compared with that in the hepatologist group (p value: 0.0237). Regarding therapy for hepatocellular carcinoma, intensive therapies were more often performed in the hepatologist group and, in addition, non-treated cases were less frequently found in the hepatologist group. Consequently, the 1-, 3- and 5-year survivals of the patients in the hepatologist group were 84.7, 61.1 and 35.1%, respectively, which were significantly longer than those in the non-hepatologist group, which were 80.7, 45.8 and 31.8%, respectively (p value: 0.0434). CONCLUSIONS: Hepatocellular carcinoma patients with cirrhosis who were treated by hepatologists can expect to obtain a longer survival because hepatocellular carcinoma tends to be detected at a smaller size, while such patients also usually receive more appropriate treatment modalities.

Aged↗

PubMed2005

Where have all the doctors gone? Career choices of Wits medical graduates.

OBJECTIVES: To assess the distribution of University of the Witwatersrand (Wits) medical graduates from 1960 to 1994 with regard to private or public sector work, chosen specialist or generalist careers, and work in urban or rural areas, looking for secular trends and gender differences. DESIGN: A cross-sectional analysis of the register of what was then the South African Medical and Dental Council (SAMDC) and a telephone interview survey of a sample of medical graduates, collecting retrospective career histories. RESULTS: Thirty-six per cent of the sample was working predominantly in the public sector, while 47% of all years worked by graduates were in the public sector. Women graduates spent 68% of their years working in the public sector, compared with 36% for men. The majority (55%) of graduates in the sample who were working in the public sector cited academic and training aspects as the main reason for this choice. Conversely, nearly half (47%) gave income as the main reason for moving to the private sector. Forty per cent of graduates had specialised (46% of men, 22% of women), while 76% were working in the large urban areas. CONCLUSIONS: The findings highlight methodological problems with standard cross-sectional analysis of distribution of personnel. They also challenge several assumptions about the likelihood of Wits graduates working as generalists (60%), the voluntary contribution of graduates to the public sector, and in particular the value of women doctors to public service and primary care.

Career Choice↗

PubMed2000

The effect of HMO penetration on physician retirement.

OBJECTIVE: To examine the effect of HMO penetration on physician retirement. STUDY DESIGN: We linked together historical data from the Physician Masterfile of the American Medical Association for successive years to track changes in physicians' activity status between 1980 and 1997. We used a multivariate discrete-time survival model to examine how the probability of physician retirement was affected by the level of HMO penetration in the physician's market area, controlling for other physician and market characteristics. The study population included all active allopathic patient-care physicians in the United States who reached age 55 between the years of 1980 and 1996. The main outcome measure was physician retirements as reported on the Physician Masterfile. PRINCIPAL FINDINGS: HMO penetration had a statistically significant positive effect on the retirement probabilities of generalists and medical/surgical specialists, but it s effect on hospital-based specialists and psychiatrists was not significant . For generalists regression-adjusted retirement probabilities were roughly 13 percent greater in high-penetration markets (HMO penetration of 45 percent ) than in low-penetration markets (HMO penetration of 5 percent ). For medical/surgical specialist s regression-adjusted retirement probabilities were roughly 17 percent greater in high-penetration markets than in low-penetration markets. CONCLUSIONS: Our findings suggest that many older physicians have found it preferable to retire rather than adapt their practices to an environment with a high degree of managed care penetration . Because the number of physicians entering the older age categories will increase rapidly over the next 20 years, the growth of managed care and other influences on physician retirement will play an increasingly important role in determining the size of the physician workforce.

Aged↗

PubMed2006

Root canal treatment in a population-based adult sample: differences in patient factors and types of teeth treated between endodontists and general dentists.

OBJECTIVE: The purpose of this study was to identify in a population-based study the differences between general dentists and endodontists with regard to types of teeth treated, fees, and patient characteristics. BASIC RESEARCH DESIGN: The "Florida Dental Care Study" was a prospective cohort study using a representative baseline sample of 873 dentate adults. In-person interviews and clinical examinations were conducted at baseline, 24 months, and 48 months, with 6-monthly telephone interviews between those times. Dental record information was abstracted afterward. RESULTS: A total of 100 root canals were performed in participants during the study period. While generalists performed the majority of endodontic procedures in all teeth, the percentage of molars treated by endodontists was significantly higher than the percentage of anterior teeth and bicuspids treated by endodontists. Data on fees were available in 85 of the cases. The trend was for endodontists fees to be higher, but the difference in fees was statistically significant only for molars. There were no statistically significant differences between generalist and specialist patients with regard to income, fear of pain, and frustration from previous dental care. However, a significantly higher percentage of patients treated by endodontists had dental insurance. CONCLUSIONS: Although the number of teeth ultimately treated in this representative sample of a dentate population was small, results do suggest that endodontists' fees were higher, they performed a higher percentage of molar root canals, and their patients were more likely to have dental insurance, as compared to general dentists who did root canals.

Chi-Square Distribution↗

PubMed2006

Generalism versus subspecialization: changes necessary in medical education.

During the initial Partners Meeting of the Association of Faculties of Medicine of Canada (AFMC), the Canadian Association for Medical Education (CAME), the College of Family Physicians of Canada (CFPC), the Medical Council of Canada (MCC), and the Royal College of Physicians and Surgeons of Canada (RCPSC) in May 2005, a plenary discussion and debate focused on the tensions that exist between generalist and subspecialty education within both the undergraduate and postgraduate educational programs in Canadian medical schools. Key issues identified in the debate included medical student selection, generalist representation on medical school faculty and in learning experiences, and the need for a greater teaching role and respect for generalism to be developed.

Canada↗

PubMed2006

Prenatal ultrasound: a tale of two cities.

At the beginning of the 21st century, community-based physicians have a technology which is safe, noninvasive and relatively inexpensive. It allows immediate access to visual data inside the body for the evaluation of health and disease. Prenatal ultrasound is vital for the efficient provision of preventive care even in community health centers, where physicians may not be the delivering physicians. To assess the frequency of this diagnostic technology, a longitudinal study of 36 months tabulated prenatal ultrasound scans performed in two community-based offices providing generalist healthcare from 2001 through 2003. Between the two offices, 68,938 patients were seen, 679 deliveries were attended and 1,286 medically indicated prenatal ultrasound examinations were performed. Prenatal ultrasound scans--compared to other common office procedures, such as electrocardiograms, chest radiographs, circumcisions, blood sugar checks, Papanicolaous and colposcopies--emerged as one of the most frequently preformed diagnostic tests in the office. Based on these results, medical educators preparing generalist physicians for community medicine may want to consider some training in prenatal ultrasound. Future research can confirm the generalizability of the findings of this pilot study in two urban health centers.

Adolescent↗

PubMed2006

Specificity and specialization of congeneric monogeneans parasitizing cyprinid fish.

Patterns and likely processes connected with evolution of host specificity in congeneric monogeneans parasitizing fish species of the Cyprinidae were investigated. A total of 51 Dactylogyrus species was included. We investigated (1) the link between host specificity and parasite phylogeny; (2) the morphometric correlates of host specificity, parasite body size, and variables of attachment organs important for host specificity; (3) the evolution of morphological adaptation, that is, attachment organ; (4) the determinants of host specificity following the hypothesis of specialization on more predictable resources considering maximal body size, maximal longevity, and abundance as measures of host predictability; and (5) the potential link between host specificity and parasite diversification. Host specificity, expressed as an index of host specificity including phylogenetic and taxonomic relatedness of hosts, was partially associated with parasite phylogeny, but no significant contribution of host phylogeny was found. The mapping of host specificity into the phylogenetic tree suggests that being specialist is not a derived condition for Dactylogyrus species. The different morphometric traits of the attachment apparatus seem to be selected in connection with specialization of specialist parasites and other traits favored as adaptations in generalist parasites. Parasites widespread on several host species reach higher abundance within hosts, which supports the hypothesis of ecological specialization. When separating specialists and generalists, we confirmed the hypothesis of specialization on a predictable resource; that is, specialists with larger anchors tend to live on fish species with larger body size and greater longevity, which could be also interpreted as a mechanism for optimizing morphological adaptation. We demonstrated that ecology of host species could also be recognized as an important determinant of host specificity. The mapping of morphological characters of the attachment organ onto the parasite phylogenetic tree reveals that morphological evolution of the attachment organ is connected with host specificity in the context of fish relatedness, especially at the level of host subfamilies. Finally, we did not find that host specificity leads to parasite diversification in congeneric monogeneans.

Animals↗

PubMed2006

Opportunities and challenges for GPs in the developing world.

Australia has a well developed system of general practice and can be proud of the quality of its generalists. In many developing countries however, the idea of a trained generalist is not well understood. The global situation creates many opportunities and challenges for Australian general practitioners. Most of us know Australian GPs who have worked in the United Kingdom or Canada. This article outlines my experiences of working in a hospital in Nepal.

Attitude of Health Personnel↗

PubMedDate not supplied

Primary care of HIV-infected adults.

HIV infection is increasingly becoming a chronic illness as effective treatment allows patients to live longer and stay healthier. HIV-infected patients often benefit from having both a generalist familiar with primary care medicine and a HIV expert involved in their care. This article is geared at the generalist who is involved with the care of HIV-infected patients and presents a series of cases to address topics important in the primary care of patients with HIV infection.

AIDS-Related Opportunistic Infections↗

PubMed1989

[Trends in the specialty of internal medicine: specialization and/or integration].

The successes of modern medicine are results of the specialisation in medicine due to the technical development. With increasing specialisation several problems for education and training, for research and medical care develop, so, for instance, a total investigation of patients is not always given on a sufficient scale. Therefore it should increasedly be orientated to an education and training to a generalist both in the training of students of the subject human medicine and during the time of specialisation in the field of internal medicine. At the same time it appears necessary to discuss more intensely the integration and/or the specialisation with the internal specialists working in practice and in research, in order to develop at first a corresponding sense for the problems and to integrate the professional status of the generalist increasedly into the self-appreciation of all specialists of internal medicine.

Ethics, Medical↗

PubMedDate not supplied

The consultant family physician.

Family physicians frequently consult and refer to other specialists, both generalist and subspecialist. Less commonly has the family physician been used as a consultant. A randomized questionnaire survey of family physicians in five midwestern states was used to consider the frequency and reasons for other specialists collaborating with the family physician as a consultant. Fifty percent of the respondents consult and refer to as well as receive consultations/referrals from other family physicians. Thirty-five percent of the respondents receive consultations and referrals from other generalist specialists, and 28 percent receive theirs from subspecialists. Most often these occur because the patient has no family physician, but family physicians are also used for their procedural skills and coordination of patient evaluation and management, including preoperative evaluation of patients. This study confirms that the consultant family physician is an important part of the health care team.

Consultants↗

PubMed1979

A teaching hospital medical clinic: secondary rather than primary care.

Although medical clinics in teaching hospitals are said to dispense primary care, the assertion has not been established by formal descriptions of care in such clinics. In this paper the authors describe 287 patient visits to a medical polyclinic (where generalists and subspecialists of internal medicine practice together) over a one-year period. The prevalence of disease was much higher than in existing descriptions of office-based primary care. The majority of visits to subspecialists involved medical problems relevant to the subspecialty, but both subspecialists and generalists dealt with medical problems across subspecialty lines because most patients had multiple problems. Although the data indicate these patients' need for accessibility, comprehensiveness, coordination, and continuity is at least as great as that of patients receiving primary care, this clinic is most appropriately described as a secondary-care facility.

Aged↗

PubMed1983

The Oslerian tradition and changing medical education: a reappraisal.

Although only 21 of Sir William Osler's 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler's teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge. Many changes have reshaped the content, process and concerns of American medical education since Osler's time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today's problems in medical education and practice.

Education, Medical↗