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Do we need more generalists?

The author identifies the confluent forces that have structured U.S. medicine in favor of specialism since World War II. He concludes that any effort to increase the number and proportion of generalists in medicine is problematic in the absence of antecedent and concurrent transformations in the structure and functioning of academic health centers and in the financing of medical care, and of major, long-lasting changes in the delivery of health care. Only after these larger considerations have been addressed can the benefits of a generalist-oriented system be anticipated. Even then, the gains expected to accrue from a greater number of generalists might prove illusory.

Academic Medical Centers↗

Meeting the faculty development needs of generalist physicians in academia.

Development of the academic environments of generalist faculty members is essential if they are to develop the skills to become leaders in medical education and primary care research and effective role models for their students. We conducted a needs assessment that included two-thirds of the generalist faculty members in family medicine, internal medicine, and pediatrics at the University of Texas Medical Branch, Galveston, Texas. The assessment was based on open-ended discussions in small focus groups and on responses to an informal checklist of 24 potential faculty development goals. The participants identified three global needs requiring significant change: (1) better understanding of and rewards for their academic activities, (2) better networking with each other and with nongeneralists, and (3) more control over their time and responsibilities. Individual needs for academic development were diverse but emphasized teaching and career-building skills. Meeting the individual needs of generalist academicians depends on addressing environmental obstacles to their academic development. We recommend building project-oriented teams that collectively develop skills in strategic planning and project management, political negotiation and public relations, and creative use of institutional support systems. Individual faculty development can then be linked to the development of high-priority group projects that stimulate learning and allow opportunities to practice new skills.

Academic Medical Centers↗

The role of the medical school admission process in the production of generalist physicians.

Medical education research has identified a number of medical student characteristics that are related to graduates' entering generalist careers. These include initial specialty preference, geographic background, gender, age, ethnicity, economic and lifestyle factors, attitudes and personal values, service orientation, and premedical academic performance. Identifying and giving weight to these factors in the medical school admission process is likely to increase the number of graduates who choose generalist specialties. This paper discusses these medical student characteristics and presents strategies that medical schools could use in the selection process to enhance the matriculation of students who are most likely to become generalists. In this way, medical schools will be able to recruit and select students who are most likely to become excellent physicians, and also produce a more appropriate balance of all specialists to meet the needs of the population.

Career Choice↗

Redesigning the surgery clerkship at MCP Hahnemann School of Medicine to address the educational needs of generalists.

This article describes how the surgery clerkship at MCP Hahnemann School of Medicine was redesigned to provide all students a well-rounded general professional education and to address the specific educational needs of generalists. During the 12-week clerkship, students spend eight weeks on two different general surgery rotations, which include significant experiences in outpatient settings. The evaluation and management of common general surgical problems, as well as the holistic approach to patient care, are emphasized. A nurse educator, recruited through funding obtained from The Robert Wood Johnson Foundation's Generalist Physician Initiative, provides formal instruction in holistic care and teaches bedside procedures. Two weeks are devoted to focused surgical subspecialty experiences addressing common conditions and are conducted primarily in outpatient settings. The remaining two weeks include an integrated musculoskeletal disease rotation, including orthopaedic surgery, rheumatology, physiatry, and radiology. Didactic teaching includes criteria for referral of patients from generalists to specialists. The new clerkship model has been well received by the students. Review of student logs for the first six months indicates the breadth of surgical experience has been maintained and appropriate balance achieved between simple and complex surgical cases. Further evaluation of the model will continue through longitudinal follow-up.

Clinical Clerkship↗

The Interdisciplinary Generalist Curriculum (IGC) project: an overview of its experience and outcomes.

The Interdisciplinary Generalist Curriculum (IGC) Project was a competitive, seven-year demonstration project funded by the Health Resources and Services Administration (HRSA). It was established to determine whether specific interdisciplinary innovations in preclinical medical school curricula could affect students' selection of careers in family medicine, general internal medicine, or general pediatrics. Through collaboration among the three generalist disciplines, the IGC innovation exposed all preclinical students in ten demonstration schools to a new or significantly enhanced preclinical curriculum that included a direct supervised clinical experience with a generalist physician preceptor. The project was managed by an interdisciplinary executive committee that was codirected by one representative each from family medicine, general internal medicine, and general pediatrics. A national advisory committee with representation from the academic and professional organizations of family medicine, internal medicine, pediatrics, and osteopathy provided input to the executive committee in guiding the project. The project was externally evaluated. Major outcomes of the IGC Project include sustained curricular changes in ten institutions, prompted by relatively few dollars and demonstration of models for collaboration at institutional and national levels. This supplement describes the IGC Project's experience and outcomes so that others may draw pertinent information to apply to their own efforts in medical education.

Curriculum↗

The Interdisciplinary Generalist Curriculum Project at the University of Colorado School of Medicine.

The University of Colorado School of Medicine first considered a longitudinal primary care preceptorship in 1992, when the dean formed the dean's Ad Hoc Committee to launch the "generalist initiative," to include a three-year required longitudinal generalist preceptorship. Being awarded an Interdisciplinary Generalist Curriculum (IGC) Project contract provided the dean's Ad Hoc Committee with the momentum it needed to enact the curriculum. This article describes the IGC Project at the University of Colorado as it was originally proposed and the intended and unintended outcomes over time. Intended outcomes included establishing early continuous clinical experiences as a vital part of the curriculum and increased exposure to primary care, while examples of unintended outcomes were the development of a longitudinal skill and behavior evaluation process and the integration of problem-based learning in the curriculum. The article concludes with a description of what is ahead for the curriculum.

Colorado↗

The Interdisciplinary Generalist Project at the University of Nebraska Medical Center.

The Interdisciplinary Generalist Curriculum (IGC) Project at the University of Nebraska College of Medicine (Nebraska) had three goals: (1) to increase first- and second-year students' exposure to primary care practice in the community; (2) to develop specific educational programs introducing these students to the principles and practices of primary care medicine; and (3) to establish a generalist coordinating council to provide leadership and to nurture generalist educational initiatives in the College of MEDICINE: Students at Nebraska were already required to spend three half-days a semester in a longitudinal clinical experience (LCE) and to complete a three-week primary care block experience in the summer between the first and second years. IGC Project funds were used increase the number of required LCE visits to five a semester and to develop curricular enhancements that would maximize the educational potential of community-based clinical experiences for first- and second-year students. Curricular elements developed included a focus on faculty development for preceptors and development of the Primary Care Introduction to Medicine Curriculum, an eight-week, interdisciplinary module scheduled late in the first year to help prepare students for intensive summer rotations. Other developments were the implementation of a pediatric physical examination experience for first-year students and the implementation of instruction in community-oriented primary care in the second year. Lessons learned are related to: (1) the value and power of early clinical experiences; and (2) the enhancing effect of a holistic, longitudinal view of the curriculum on the planning of early clinical experiences.

Curriculum↗

Comparison of endodontist versus generalist regarding preference for postendodontic use of cotton pellets in pulp chamber.

A degree of uncertainty exists about the use of cotton pellets in the pulp chamber after canal obturation. The purpose of this study was to poll practicing endodontists and generalists regarding their preference. Forty-six endodontists and an equal number of general dentists were polled in a mail survey regarding their preferences for the use of a cotton pellet in the pulp chamber after canal obturation. Eighty-seven percent of the endodontists and 54% of the generalists responded. Of the endodontists, 62.5% said they thought that the general dentist wanted a cotton pellet, contrasted to 80% of the generalists. The difference in proportions was not statistically significant.

Attitude of Health Personnel↗

AIDS specialist versus generalist ambulatory care for advanced HIV infection and impact on hospital use.

We examined patterns of ambulatory care in the year before diagnosis of acquired immune deficiency syndrome (AIDS) for 5,720 persons infected with human immunodeficiency virus (HIV) who were continuously enrolled in the New York State Medicaid program and diagnosed in 1984-90. For 3,175 persons followed > or = 6 months after AIDS, we also examined the change between the year before AIDS diagnosis and the 6 months afterward in the predominant provider who was seen most frequently and at least twice. Approximately 75% of the population had a predominant provider identified. Of this group, 43% of the patients had a generalist as their predominant provider before AIDS diagnosis, falling to only 25% after diagnosis. The proportion with an AIDS specialist predominant provider increased from 22% before AIDS diagnosis to 39% afterward (P < 0.001). Patients with a generalist predominant provider before AIDS diagnosis had higher odds of switching providers and of hospitalization after AIDS diagnosis than patients with an AIDS specialist predominant provider. If generalists are to be encouraged to manage patients with advanced HIV disease, a better understanding of factors contributing to these outcomes is needed.

Acquired Immunodeficiency Syndrome↗

The importance of the ontogenetic niche in resource-associated divergence: evidence from a generalist grasshopper.

Geographic variation in resource use can produce locally adapted populations that exhibit genetic and phenotypic divergence. In the bird-winged grasshopper (Schistocerca emarginata = [lineata]), we investigate whether genetic data exist in accordance with geographic variation in resource (host) use and coloration. In Texas, juvenile grasshoppers feed almost exclusively on one of two host plants, Rubus trivialis (Rosaceae) or Ptelea trifoliata (Rutaceae), whereas adults of both forms are dietary generalists and consume many plants from unrelated families. Along with differences in juvenile feeding, differences in a density-dependent color polyphenism are concordant with genetic (mitochondrial DNA) variation among eight populations of the bird-winged grasshopper. Forms feeding on R. trivialis and those feeding on P. trifoliata represent monophyletic lineages according to phylogenetic analysis and maximum-likelihood tests of two alternative phylogeographic hypotheses for geographic variation in host use. Character-state optimization of host-plant acceptability on a phylogeny containing S. emarginata and outgroup taxa indicates that populations consuming R. trivialis gave rise to populations consuming P. trifoliata. Juvenile grasshoppers that consume P. trifoliata acquire deterrence against predation, suggesting that enemy-free space facilitated this host shift. In extant populations, adaptations stemming from alternative resource use during ontogeny present possible barriers to gene exchange. This study represents the first demonstration of resource-associated divergence in an otherwise generalist insect that exhibits temporal variation in resource use, characterized as developmental changes in host specialization. Our findings suggest that exploitation of different resources may have unexplored significance for generalist species that compartmentalize specialization to particular life stages.

Amino Acid Sequence↗

Spatial segregation of specialists and generalists in bird communities.

Each species generally has a close relationship with one or more habitats and can therefore be classified as either specialist or generalist. We studied whether specialist and generalist species are spatially distributed independently of each other. Repeating the analysis for 100 of the most frequent terrestrial bird species recorded over the 10 000 sampled sites of the French Breeding Bird survey, we found that specialists were more abundant if the rest of the community was specialized, and that the inverse was also true. This pattern was far subtler than just a simple dichotomy: most species actually presented a maximum abundance at a value of community specialization similar to their own level of specialization. Bird communities appear very well defined along a specialist-generalist gradient. We believe this pattern becomes more apparent with habitat degradation. The consequences on both ecological services and community resilience may well be considerable.

Animals↗

Impact of generalist care managers on patients with diabetes.

OBJECTIVE: To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes. STUDY SETTING: Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network. STUDY DESIGN: A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients. DATA COLLECTION: Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels. PRINCIPAL FINDINGS: In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n=1,185) versus the control group (n=4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c <7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant. CONCLUSIONS: Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

Adolescent↗

Preventive content of adult primary care: do generalists and subspecialists differ?

We compared preventive care performed by 20 generalists and 20 subspecialists practicing in Santa Clara and San Mateo Counties, California, by auditing charts of adult primary care patients for compliance with recommendations of the Canadian Task Force on the Periodic Health Examination. Generalists and subspecialists both provided 49 per cent of recommended preventive services. The two groups did not differ significantly in performance of any individual service. Performance varied widely within both groups. Of many factors explored, only two were associated with more preventive services: provision of a complete physical examination to the patient, and a physician's belief in the importance of a given service. The "generalist vs. subspecialist" debate assumes that a physician's specialty classification is an important predictor of behavior. For the performance of preventive care, this was not true in our study. Instead, physicians' beliefs and practice habits may be major determinants of the quality of preventive care provided. These exploratory findings needed confirmation in other settings.

Adult↗

The impact of multiple predictors on generalist physicians' care of underserved populations.

OBJECTIVES: This study examined the relative and incremental importance of multiple predictors of generalist physicians' care of underserved populations. METHODS: Survey results from a 1993 national random sample of 2955 allopathic and osteopathic generalist physicians who graduated from medical school in 1983 or 1984 were analyzed. RESULTS: Four independent predictors of providing care to underserved populations were (1) being a member of an underserved ethnic/minority group, (2) having participated in the National Health Service Corps, (3) having a strong interest in practicing in an underserved area prior to attending medical school, and (4) growing up in an underserved area. Eighty-six percent of physicians with all 4 predictors were providing substantial care to underserved populations, compared with 65% with 3 predictors, 49% with 2 predictors, 34% with 1 predictor, and 22% with no predictors. Sex, family income when growing up, and curricular exposure to underserved populations during medical school were not independently related to caring for the underserved. CONCLUSIONS: A small number of factors appear to be highly predictive of generalist physicians' care for the underserved, and most of these predictive factors can be identified at the time of admission to medical school.

Career Choice↗

Reach out and teach someone: generalist residents' needs for teaching skills development.

BACKGROUND AND OBJECTIVES: Family practice residents and students receive substantial teaching from senior residents. Yet, we lack data about residents' needs for teaching skills development, particularly in generalist training. This multicenter, interdisciplinary study describes the learning needs of generalist residents for becoming more effective teachers. METHODS: One hundred medical students, residents, and faculty infamily medicine, internal medicine, and pediatrics participated in 11 focus groups and 4 semi-structured key informant interviews at the University of California, Irvine and the University of California, Los Angeles in 2000-2001. RESULTS: Participants agreed that resident teachers fulfill critical roles in medical education, providing powerful, skills-based teaching that can tangibly benefit both residents themselves and their junior learners. House staff often facilitate students' best learning experiences despite inherent risks in serving as teachers and professional role models. Residents need teaching skills training that prepares them to lead clinical teams and teach students essential skills that include history taking and physical examination, critical reasoning, charting, and procedures. CONCLUSIONS: Generalist residents fulfill important roles as practical clinical teachers and role models for junior learners. Future research should address how resident teachers affect learners' clinical skills, academic performance, and professionalism.

California↗

Generalist courses in US medical schools and their relationship to career choice.

We conducted a survey of required first-year generalist courses offered by US medical schools during 1980, 1985, and 1990 to see if significant growth had occurred in this curricular area and to determine if the presence of these courses was associated with an increase in the percent of graduates selecting family practice as a career option. During the 1980s, only two types of generalist courses were offered by more than 50% of US medical schools, clinical experience and human behavior/psychiatry courses, with significant growth occurring in only two types of generalist courses, ethics and medical humanities courses. The presence of a required clinical experience course in 1985 was associated with a 2% increase in the number of graduates selecting family practice as a career option in 1988.

Career Choice↗

Subspecialisation in obstetrics and gynaecology--whither (or wither) the generalist.

In 1987, Council of the Royal Australian College of Obstetricians and Gynaecologists (RACOG) established its subspecialisation committee who identified subspecialty groups. It was the belief of the subspecialty committee that specialty training was necessary if haphazard evolution of the subspecialties and fragmentation within the discipline of obstetrics and gynaecology was to be avoided. The major issues of such training are manpower considerations and the time committed to the subspecialty, its effect on research and whether the generalist obstetrician and gynaecologist has been disadvantaged by such an initiative. Research initiatives must not suffer and the subspecialist should be prominent in the respective fields informing colleagues of important clinical and research advances. Undoubtedly the workload of the generalist will be eroded but their importance in the practice of obstetrics and gynaecology must be strengthened. The generalist should be encouraged to assist in the management of the patient in association with the subspecialist and referral should be on a tertiary basis. The limits of subspecialisation must be clearly defined and the availability and distribution of subspecialists determined. The numbers should be carefully monitored and training and accreditation and certification of subspecialists should remain within a central body such as the RACOG.

Gynecology↗

Pediatric generalist training: graduate medical education at a crossroads.

There is a growing consensus that the United States is training more physicians than it needs or can afford. Public resources are likely be used to bend the graduate medical education enterprise increasingly toward the production of generalist physicians to practice primary care. Pediatrics, with its generalist tradition, can stand tall at this crossroads if it renews its commitment to training high quality generalists and assumes a leadership position as graduate medical education moves from the hospital into the community.

Education, Medical, Graduate↗