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PubMed1982

Job content and pharmacists' job attitudes.

The relationships between job content and hospital pharmacists' work attitudes are examined. A 152-item questionnaire was mailed to 507 hospital pharmacists in southeastern Michigan. The questionnaire included measures of job dimensions, psychological states, and personal and work outcomes. Mean scores for 34 subscales consisting of 2-5 related items were computed. Background characteristics were also assessed. Using factor analysis, the respondents were categorized as clinical, inpatient, outpatient, or generalists depending on their reported relative time spent performing 23 nonadministrative job functions. Analysis of variance was performed across the four groups for each subscale; the level of significance was set at 0.001. The response rate was 56%, representing 283 completed questionnaires. The clinical, outpatient, inpatient, and generalist pharmacist groups consisted of 43, 36, 70, and 134 respondents, respectively. There was a prevalent trend in the rank order in which pharmacists in the four groups responded to various subscales. The clinical group had the highest scores for 13 of the 14 subscales that were significantly different across pharmacist groups. Alternatively, in all but one of the significantly different subscales the inpatient group ranked lowest. Because pharmacists in the clinical group consistently scored higher than the other groups on scales measuring components of job enrichment, the authors concluded that the challenge of hospital pharmacy managers is to adapt the positive features of clinical practice to other areas of the profession.

Attitude of Health Personnel↗
PubMed1982

Practitioners view dietetic roles for the 1980s.

A study was conducted among practitioners in Pennsylvania to obtain their opinions concerning essential entry-level competencies and those that they considered necessary when hiring and entry-level dietitian, and to determine how they felt about role specialization at the entry level or practice. The competencies identified as most critical for the entry-level dietitian were: (a) an understanding of the managerial processes of planning, organizing leading, evaluating, and controlling and their relationship to the management of human, material, and financial resources; (b) an understanding of the process, functions, and interrelationships of various systems of the human body; and (c) an ability to integrate knowledge of biological, social, and professional sciences into a comprehensive concept of human nutrition. A strong knowledge base, essential for the entry-level generalist, was indicated in the following areas: nutrition and disease, normal nutrition, food selection and planning, and food production systems. There was a perceived need for academic institutions to train both specialists and generalists in the 1980s.

Competency-Based Education↗
PubMed1982

Role ambiguity, role conflict, and job satisfaction of dietitians.

The purpose of this research was to study the relationship between role ambiguity and conflict and job satisfaction as perceived by dietitians in the United States. Role ambiguity scores for all dietitians were consistently low. Generalist dietitians, however, scored significantly higher in role ambiguity than dietitians who were heads of departments and dietitians who were in the other/private practice group. Role conflict scores were considerably higher for all dietitian groups than scores for role ambiguity. Yet, for most groups, role conflict scores were only slightly higher than mid-point. Generalist dietitians scored significantly higher in role conflict than did six other groups of dietitians. There were no significant correlations between role ambiguity or conflict and job satisfaction.

Conflict, Psychological↗
PubMed1995

Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study.

OBJECTIVE: To compare the outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus (NIDDM) who were cared for in three different systems of care and by generalist and subspecialist physicians. DESIGN: An observational study with follow-up at three periods: (1) a 2-year study of 532 patients with hypertension and 170 patients with NIDDM who had entrance and exit histories, physical examinations, and laboratory tests; (2) a 4-year follow-up of 1044 patients with hypertension and 317 patients with NIDDM based on patient-reported functional status; and (3) 7-year mortality for 1296 patients with hypertension and 424 patients with NIDDM. SETTING AND PARTICIPANTS: Patients sampled from health maintenance organizations, large multispecialty groups, and solo or single-specialty group practices in Boston, Mass, Los Angeles, Calif, and Chicago, Ill. Patients were designated as belonging to one of three systems of care: fee for service; prepaid patients in solo or small single-specialty groups or in large multispecialty group practices, referred to as independent practice associations; and staff-model health maintenance organizations. The principal providers were family practitioners, general internists, cardiologists, or endocrinologists. MAIN OUTCOME MEASURES: Physiological, functional, and mortality. For hypertension, we measured blood pressure and stroke incidence. For NIDDM, we measured blood pressure, glycosylated hemoglobin level, visual function, vibration sense, ulcers and infections in the feet, and albumin excretion rate. Functional outcomes were assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Mortality was assessed for the 7 years following the entrance examination. RESULTS: We found no evidence that any one system of care or physician specialty achieved consistently better 2-year or 4-year outcomes than others for patients with NIDDM or hypertension. Endocrinologists appeared to achieve better foot-ulcer and infection outcomes for patients with NIDDM, particularly when compared with family practitioners. However, no other specialist differences were found in any individual measures for either condition. Moreover, no adjusted mortality differences among systems or among physicians specialties were observed in the 7-year follow-up period. CONCLUSION: No meaningful differences were found in the mean health outcomes for patients with hypertension or NIDDM, whether they were treated by different care systems or by different physician specialists. Although prepaid medicine relies more heavily on generalist physicians than does fee for service, there is no evidence from these analyses that the quality of care of moderately ill patients with these two common disease was adversely affected. These findings must be viewed in light of the historically higher costs of fee-for-service medicine and of subspecialty physician practice.

Analysis of Variance↗
PubMed1995

John M. Eisenberg, MD.

The complicated interaction between government, academic medical centers, health care payers, and burgeoning market forces has tested the leadership skills of a generation of academicians with little formal training in economics. The emergence of a new breed of physician investigator with solid business credentials has therefore proved attractive to many segments of the medical community. John M. Eisenberg received his MD from Washington University in 1972, his MBA from the Wharton School in 1976, and shortly thereafter headed the division of general internal medicine at the University of Pennsylvania. In addition to championing the role of the generalist in health care delivery, Eisenberg has also played a major part in the reformation of Medicare reimbursement. He has been a commissioner on the Congressional Physician Payment Review Commission since 1986, serving as chairman since 1993. After assuming the chairmanship of the department of medicine at Georgetown University in 1992, Eisenberg served as an advisor to the Clinton administration during its efforts towards national health care reform. Interviewed in his office in Georgetown, Eisenberg reflected on the economic forces twisting post-graduate medical education, the role of non-physician providers in future health care delivery, and the evolving relationship between specialists and generalists.

Economics, Medical↗
PubMed1995

Preventable hospitalizations and access to health care.

OBJECTIVE: To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style. DESIGN: Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas. SETTING: Community based. PARTICIPANTS: A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities. MAIN OUTCOME MEASURES: We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style. RESULTS: Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions (R2 = 0.50; P < .001). In a multivariate analysis that included a measure of access, the prevalence of conditions, health care seeking, and physician practice style to predict cumulative hospitalization rates for chronic medical conditions, both self-rated access to care (P < .002) and the prevalence of the conditions (P < .03) remained independent predictors. CONCLUSION: Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions.

Adult↗
PubMed1994

Patterns of ambulatory care for AIDS patients, and association with emergency room use.

OBJECTIVE: We examined the association of patterns of ambulatory care for AIDS patients with any use of the emergency room (ER) and the monthly rate of ER visits in the six months after AIDS diagnosis. DATA SOURCES/STUDY SETTING: The study population was obtained from the New York State Medicaid HIV/AIDS Research Data Base and includes patients diagnosed with AIDS from 1983 to 1990. DATA COLLECTION/EXTRACTION METHODS: To examine patterns of care and ER use not leading to hospitalization, we studied patients who survived at least six months after their first AIDS-defining diagnosis. The data base included person level information on visits to different provider sites and patient demographic and clinical characteristics. STUDY DESIGN: We defined the dominant provider as the site delivering the majority of ambulatory care for patients with a minimum of four ambulatory visits in the six months after AIDS diagnosis. Dominant providers were classified by specialty and setting: generalist physician; general medicine clinic; AIDS specialty clinic; and other specialty clinic or physician (e.g., cardiology). Patients without a dominant provider were grouped into those with four or more visits and those with fewer than four visits. Regression analysis was used to estimate relationships between ER use and patterns of ambulatory care and patient demographic and severity of illness characteristics. PRINCIPAL RESULTS: The study population included 9,155 AIDS patients aged 13 to 60 years at diagnosis, continuously Medicaid-enrolled, and surviving at least six months after AIDS diagnosis. Among those with four or more visits (56 percent), over 70 percent had a dominant provider. Overall, 39 percent of the study population visited the ER while, in the group with four or more visits, 53 percent of those without a dominant provider had an ER visit. Patients without a dominant provider were estimated to have 32 percent higher odds of ER use than patients with a dominant provider. Among patients with a dominant provider, patients with a generalist or primary care clinic dominant site of care were estimated respectively to have 18 percent and 23 percent lower odds than patients with an AIDS specialty clinic as the dominant site of care. Drug users had higher odds of ER use, as did women. CONCLUSIONS: In this Medicaid AIDS population, a dominant provider delivering the majority of a patient's care was associated with less use of the ER by the patient. Among patients with a dominant provider, ER use was lowest for those with a primary care provider. Further examination of the type and availability of ambulatory services in AIDS specialty clinics and primary care settings, as well as more detailed information on patient characteristics, may reveal reasons for these patterns of ER use.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Results of the 1994 National Resident Matching Program: family practice.

The 1994 National Resident Matching Program results reveal a 14% increase in positions filled in family practice residencies, compared with 1993 (2,293 vs 2,002) and a 13% increase in positions filled by US seniors (1,850 vs 1,636). Similarly, 9% more positions were filled on July 1, 1994, than 1993 (3,040 vs 2,798). For the first time, in 1994 more than 3,000 first-year residency positions were filled in family practice. One hundred more US seniors matched in internal medicine, and 74 more US seniors matched in pediatrics. Given the anticipated career choices of students entering residency training in the generalist disciplines, it is expected that 31% of the class of 1994 (Liaison Committee on Medical Education (LCME)-accredited medical schools) will practice as generalists. An 8% increase in first-year positions offered, and the development of 10% new Accreditation Council for Graduate Medical Education-accredited family practice residency programs could accommodate 20% of the nation's graduates of LCME- and American Osteopathic Association-accredited medical schools. With increasing interest in family practice careers, increased support for the nation's family practice residency programs is critical.

Accreditation↗
PubMed1994

Mental health services in Army primary care: the need for a collaborative health care agenda.

Epidemiologic studies have shown that more than half of mentally ill patients in the United States receive their psychiatric care exclusively in primary care settings. This fraction may be even higher in the military due to concern over possible occupational repercussions resulting from use of specialty psychiatric care and specialist shortages. Collaboration between generalists and mental health care specialists could potentially improve mental health care delivery and reduce psychiatric disability for a large segment of the Army population who have a psychiatric disorder but may not seek specialty care. Collaborative efforts can reinforce military generalists' essential gate-keeping function, thereby decreasing unnecessary medical utilization and health care costs. The authors review the problems associated with mental health care delivery in primary care and provide examples of collaborative models previously studied or currently being explored. A four-part Army Primary Care-Mental Health Services Agenda is proposed, consisting of: (1) coordinated research including primary care-mental health services research and community-based epidemiologic studies; (2) formation of a primary care-mental health services advisory committee for aiding with policy and program development; (3) graduate and continuing medical education in primary care-mental health services emphasizing interdisciplinary collaborative skills; and (4) clinical implementation of feasible collaborative interdisciplinary mental health care models adapted to the range of unique Army primary care settings. The main goal of the Army Primary Care-Mental Health Services Agenda is to improve access to Army mental health care in the most efficacious and cost-effective way and to help minimize the organizational impact of disability related to psychosocial distress.

Cross-Sectional Studies↗
PubMed1994

The outlook for osteopathic medical specialists within a reformed healthcare system.

Osteopathic specialists enjoy the unique advantages of practicing in a profession with the recommended mix of generalists and specialists as healthcare reform heats up. Ironically, market reforms, driven by cost-containment, challenge the infrastructure of osteopathic physician practice, hospital care, and osteopathic education, all of which support the generalist/specialist mix that healthcare reformers are trying to attain. The authors trace the development of specialties in the osteopathic medical profession in response to persecution and isolation, and explain the differences between allopathic and osteopathic medical specialists. They document the rationale of a physician mix favoring an increased proportion of generalists. Finally, they argue persuasively that no one has a stronger motivation to help position the osteopathic medical infrastructure for survival than the osteopathic medical specialist.

Health Care Reform↗
PubMed1994

The internal medicine clerkship and the national debate on primary care education.

The required internal medicine clerkship has a mission greater than most educational experiences within the medical school. It is being looked upon to enhance student interest in and training for generalist careers. In the rush to meet this mandate, the centrality of the clerkship to educating all physicians cannot be violated. Achieving an effective balance among the competing educational demands will require creative thinking on the part of clerkship directors, chairs, and faculty. The types of patients students interact with and learn from must embody the clerkship's learning objectives. The "core curriculum" for internal medicine clerkships must be defined and differentiated from a generalist curriculum. The faculty must be chosen for their teaching effectiveness and commitment. Teaching medical students is a privilege, not an entitlement for medical school faculty. Learning must occur in a context representative of the practice of internal medicine and in an environment conducive to education. It is truly a time of change in internal medicine clerkships. CDIM is working to provide a foundation upon which the education of the physicians of tomorrow can be built.

Education, Medical↗
PubMed1994

The Ides of March. The match 1993 in perspective.

BACKGROUND: The total number of US medical school graduates who selected categorical programs in internal medicine in this year's match fell by 7.9%. Consequently, the program fill rate for US graduates declined for the eighth consecutive year, from 55.9% to 53.1%. Preliminary positions and international graduates continue to increase, though questions remain whether these residents serve as good role models to encourage student interest in internal medicine. METHODS: We reviewed the 1993 National Resident Matching Program data and several curricular reforms implemented in our internal medicine clerkship and residency program to evaluate whether such reform might enhance interest in general internal medicine. RESULTS: Reform in our internal medicine clerkship curriculum included increased emphasis on problem-based learning and exposure to generalist role models. This resulted in substantial increases on the average miniboard examination and a 22% increase in the number of students pursuing residency in internal medicine from the previous year. Residency curricular reform centered around enhanced ambulatory care teaching along with improved exposure to generalist role models. This resulted in a gradual increase in the number of residency graduates who were staying in general internal medicine from 21% in 1991 to 40% in 1993. CONCLUSIONS: Innovative curricular changes in our internal medicine clerkship and residency programs have led to enhanced interest in general internal medicine. Although our results are preliminary, such change is necessary, not only to continue program excellence, but for simple survival.

Internal Medicine↗
PubMed1994

Pharmacologic considerations in the management of oral surgery patients in general dental practice.

Minor oral surgery is an integral part of dentistry, whether performed by the generalist or the specialist. Procedures include those within the broad discipline of general oral surgery (such as routine and surgical extractions, impactions, preprosthetics, biopsy, and implants), periodontics (such as periodontal surgery, mucogingival plastic surgery, and implants), and endodontics (periapical surgery). There is considerable overlap among generalists and surgical specialists in terms of the treatment provider. Perhaps the most important consideration with regard to appropriateness and quality of care is not who does the surgery but how it is done. The ability to perform surgery according to sound surgical principles and to properly prescribe medications in association with that surgery is a necessary requisite for quality treatment. This article reviewed how various pharmacologic agents can be administered and how they influence surgical procedures. Whether or not they are used and the manner in which they are used are predicated on the discretion and clinical judgment of the clinician on a case-by-case basis. If used appropriately, these medications can be instrumental in mitigating morbidity and increasing tolerance and overall patient satisfaction with the surgical experience.

Analgesia↗
PubMed1993

The results of 20 years of family practice residency training at the University of Louisville.

In response to shortages of generalist physicians, especially in rural areas, family practice residency programs were established at both of Kentucky's medical schools. In 1972 a family practice residency program became operational at the University of Louisville. A study was conducted to determine the effectiveness of this program. We were especially interested in those factors that were associated with a physician's choice to practice in rural or urban medically underserved areas. The records of the 100 program graduates were reviewed to determine the physician's gender, ethnic background, hometown, and current practice location. A questionnaire was mailed to program graduates to obtain additional information about factors that influence physician practice location. For the purpose of this study, "rural" was defined as a community of less than 25,000. Sixty-eight of the program's 100 graduates currently practice in Kentucky. Forty-nine graduates serve patients in rural or medically underserved urban areas, and of those, 31 are located in Kentucky. Whites and those from rural hometowns were more likely to practice in rural communities than minorities or those from urban hometowns. However, minorities were more likely than whites to practice in medically underserved urban areas. No association was found between gender and practice location. Initial interest in rural practice and participation in financial aid programs requiring service in a rural area were associated with rural practice location, but participation in rural rotations at the predoctoral or residency training level were not. We conclude that the family practice training program at the University of Louisville has been successful in training generalist physicians to serve rural and medically underserved urban populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Family Practice↗
PubMed1993

Results of the 1993 National Resident Matching Program.

The 1993 NRMP results reveal a 19% increase in positions filled in family practice residencies compared to 1992 (2,002 versus 1,658) and a 17% increase in positions filled by US seniors (1,636 versus 1,398). Similarly, 11% more positions were filled on July 1, 1993, than 1992 (2,798 versus 2,530). This confirms a trend begun in 1992 of increased interest in careers in family practice, reversing four years of declining interest from 1988 to 1991. Two hundred one fewer US seniors matched in internal medicine, while 36 more chose pediatrics. Of students entering residency training in the generalist disciplines, it is expected that 27% of the class of 1993 (LCME-accredited medical schools) will practice as generalists. An increase of 9% of first-year positions offered, and the development of 15% new ACGME-accredited family practice residency programs, could accommodate 20% of the nation's graduates of LCME- and AOA-accredited medical schools. With increasing interest in careers in family practice, increased support for the nation's family practice residency programs is critical.

Career Choice↗
PubMed1995

Results of the 1995 National Resident Matching Program: family practice.

The 1995 National Resident Matching Program (NRMP) results broke records in the number of positions filled in family practice residencies, with an increase of 11.8% over 1994 figures (2,563 vs 2,293) and an increase of 12.5% in positions filled with US seniors (2,081 vs 1,850). This is the largest number of US seniors choosing family practice in the NRMP's history. In keeping with the trend that began in 1992, 7% more positions were filled on July 1, 1995, than were filled at the same time in 1994 (3,252 vs 3,040). Internal medicine residencies matched 74 more US seniors in 1995, and pediatric residencies matched 84 more US seniors. Given the anticipated career choices of students entering residency training in the generalist disciplines (95% of students matching in family practice, 60% of students matching in pediatrics, and 45% of students matching in internal medicine), it is expected that 33.5% of the class of 1995 (Liaison Committee on Medical Education-accredited medical schools) will practice as generalists. First-year positions offered in family practice through the NRMP increased 6%, and the number of Accreditation Council on Graduate Medical Education-accredited family practice residency programs increased 3% (421 vs 410). With continued increased interest in family practice as a career choice and the need for more family physicians, support for the nation's family practice residency programs continues to be of critical importance.

Adult↗
PubMed1996

Should general surgeons perform specialty procedures? An outcome experience with reduction mammoplasty.

Recent health care reform proposals have emphasized the need for "generalists" over "specialists." Particularly targeted are the "surgical specialties." If much of this reform comes to pass, this may leave patients for whom the only surgical care may come from the general surgeon. In this setting, opportunities exist for the general surgeon to provide services that now are claimed by surgical specialists. This study reports the outcome experience of one general surgeon providing one such procedure, reduction mammoplasty, to a beneficiary population. Over a 26 month period, 50 reduction mammoplasties were performed. An average of 1527 grams of breast tissue were removed from each patient. There were no episodes of nipple necrosis or other complications requiring reoperation. At 1-26 months follow-up, all patients had relief of presenting symptoms, 90 per cent of patients had normal nipple sensation; all patients were satisfied with the results and would have the operation again by the same surgeon. These results show that a motivated and well-trained general surgeon can provide specialty surgical care to a potentially underserved population. General surgeons should be allowed to develop and practice the full range of skills they will need to take advantage of the opportunities that will be available to the surgical "generalist."

Adolescent↗
PubMed1996

The initial employment status of physicians completing training in 1994.

OBJECTIVE: To gain information about the career status of residents who completed graduate medical education training programs in selected specialties and subspecialties during the 1993-1994 academic year. DESIGN: A descriptive one-page survey of residency program directors, including two mailed follow-up surveys, was conducted from January 1, 1995 to June 1, 1995. SETTING: Directors of residency programs in 26 specialties and subspecialties accredited by the Accreditation Council for Graduate Medical Education, totaling 4369 programs. MAIN OUTCOME MEASURES: Program directors identified the number of resident physicians who completed the program, the known career status of those physicians, the number of physicians who had experienced difficulty finding a practice position, the characteristics of the full-time clinical practice positions, and the number of physicians who could not find full-time employment. The perceptions about likely trends in the availability of practice opportunities for graduates in the future and the likely change in the number of resident positions were also assessed. RESULTS: A total of 3090 program directors (70.7%) completed the survey. Respondents reported that 15999 resident physicians completed training in one of the 26 specialties and subspecialties, and 63.2% of these graduates were potentially seeking a professional position. Most of those not seeking a position were pursuing additional training (92.9%). Of those seeking employment, the percentage who did not find a full-time position in their specialty or subspecialty ranged between none in urology to 10.8% in pathology. Across all specialties, about 70% of graduates looking for full-time positions entered clinical practice in their specialty of training. Physicians pursuing generalist careers had fewer problems finding preferred positions than those pursuing nongeneralist specialties. Finally, program directors in most nongeneralist specialties believed that the degree of difficulty their graduates will experience in finding a full-time practice position will increase during the next year. CONCLUSIONS: Physicians attempting to enter practice in some specialties and in some regions of the country are experiencing difficulty. In some cases up to 10% of the resident physicians did not find full-time positions in their specialty or subspecialty. The differences noted between the generalist and nongeneralist specialties are consistent with widespread perceptions about the current market. These data establish the baseline for analyzing trends.

Data Collection↗