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PubMed1994

General surgical practice patterns in Nova Scotia: the role of the "generalist" general surgeon.

OBJECTIVE: To determine the role of traditional "generalist" general surgeons in Nova Scotia. DESIGN: An anonymous mail survey. SETTING: The Province of Nova Scotia. PARTICIPANTS: Sixty-two active general surgeons listed on the Nova Scotia Provincial Medical Board Registry. INTERVENTIONS: A questionnaire to compare the practice patterns of community surgeons, regional surgeons and tertiary care surgeons. MAIN OUTCOME MEASURES: The availability of non-general-surgery subspecialty colleagues in the hospital setting, the extent of non-general-surgery subspecialty practices of the participating surgeons, the types of procedures they commonly perform and the adequacy of their general surgery training to meet their present practice requirements. RESULTS: The questionnaire response rate was 79%. Community surgeons had few non-general-surgery subspecialty colleagues, and the majority maintained broad "generalist" general surgical practices. Regional surgeons had more non-general-surgery subspecialty colleagues, but many still had surgical practices that included the non-general-surgery subspecialties. Tertiary surgeons had adequate non-general-surgery subspecialty colleagues and maintained narrow general surgery practices. CONCLUSIONS: In Nova Scotia, "generalist" general surgeons presently provide non-general-surgery subspecialty services in both regional and community hospital settings.

Data Collection↗
PubMed1993

AAMC policy on the generalist physician.

In 1992 the Association of American Medical Colleges created the Generalist Physician Task Force to develop a policy statement for the AAMC and to recommend ways to help reverse the trend away from generalism. The task force strongly endorsed using private-sector initiatives exerted through consensus and voluntary cooperation, although recognizing the indispensable role of government in defining the magnitude of the need for generalist physicians and in eliminating barriers to meeting the need. As a policy, the AAMC advocates an overall national goal that a majority of graduating medical students be committed to generalist careers (family medicine, general internal medicine, or general pediatrics) and that appropriate efforts be made by all schools so that this goal can be reached within the shortest possible time. To further this goal, the task force recommended strategies for the AAMC, schools of medicine, graduate medical education, and the practice environment.

Family Practice↗
PubMed1996

A comparison of dermatologists and generalists. Management of childhood atopic dermatitis.

BACKGROUND AND DESIGN: To compare the approaches of generalist physicians and dermatologists in the management of childhood atopic dermatitis (AD), a 6-page questionnaire was developed to assess specific practice characteristics and therapeutic preferences. Surveys were mailed to all board-certified dermatologists in North Carolina (n = 173) and to a sample of pediatricians (n = 200) and family medicine physicians (n = 300) randomly selected from the North Carolina Health Professions Database. There were 307 eligible respondents, defined as those who see children with AD, and 112 ineligible respondents. The response rate of eligible respondents was 62%. The specialty-specific response rates were as follows: 76% for dermatologists, 70% for pediatricians, and 49% for family medicine physicians. RESULTS: Dermatologists reported seeing the largest number of patients with AD, followed by pediatricians and family medicine physicians. Dermatologists also reported seeing the highest percentage of pediatric patients with moderate or severe AD (59%), followed by pediatricians (27%) and family medicine physicians (19%). Regardless of the severity of the AD, dermatologists consistently indicated a greater preference for more intensive therapy compared with generalists, as demonstrated by their preference for prescribing more potent topical steroids. Also, dermatologists were more likely than pediatricians (22%) and family medicine physicians (8%) to report "frequent use" of oral antibiotics for AD (63%). CONCLUSIONS: These striking interspecialty differences are likely to affect the outcome and cost of care of childhood AD. The data support the argument for conducting further studies of generalists' and dermatologists' approach to childhood AD, correlating therapeutic approaches with clinical outcomes and costs.

Child↗
PubMed1997

A study of the role of the generalist oncology nurse as a basis for revision of the blueprint for certification.

PURPOSE/OBJECTIVES: To delineate the current role of the generalist oncology nurse as a basis for revision of the blueprint for the OCN Exam. DESIGN: Survey of generalist oncology nurses. SAMPLE: 1,200 oncology nurses randomly chosen from the general membership of the Oncology Nursing Society who completed and returned surveys. METHODS: Surveys developed by subject matter experts and mailed by American College Testing. MAIN RESEARCH VARIABLES: Frequency and importance of 201 oncology nursing activities previously identified by a group of experts in oncology nursing. FINDINGS: Highest ranked items for combined frequency and importance pertained to comfort, information, protective mechanisms, and coping. Lowest ranked items pertained to prevention, detection, research, and sexuality. CONCLUSIONS: The blueprint was redesigned to include eight domains of practice: quality of life (27%), gastrointestinal and urinary function (15%), protective mechanisms (15%), scientific basis for practice (12%), cardiopulmonary function (10%), health promotion (8%), oncologic emergencies (7%), and professional performance (6%). IMPLICATIONS FOR NURSING PRACTICE: Because oncology nursing is changing, it is necessary to reconfirm and update the blueprint for the certification exam. Certification exams for the generalist nurse beginning in May 1996 were based on this updated blueprint.

Adult↗
PubMed1997

Teaching medical students in community-based practices: a national survey of generalist physicians.

BACKGROUND: This study was undertaken to determine the extent of medical student teaching by community-based generalists, differences between teachers and nonteachers, and physicians' perceptions and attitudes about teaching. METHODS: Two questionnaires were mailed to a random sample of 4974 generalist physicians in community-based practice in the United States including family physicians, general internists, and general pediatricians. The first survey instrument was a postcard with two questions; the second was a 4-page questionnaire sent to postcard responders. These mailings were supplemented by a telephone survey of nonresponders. RESULTS: Forty-two percent responded to the postcard, and, of those, 47% responded to the questionnaire. Adjusted by the results of a telephone survey of postcard nonresponders, 30% of family physicians and general pediatricians and 20% of general internists taught medical students in their offices. The average teaching physician worked with three students per year for approximately 10 days each. Family physicians and general internists who had community-based educational experiences while in medical school were more likely to be teachers. Teachers were somewhat younger than nonteachers (year of medical school graduation 1977 vs 1973), but there were few other differences. Controlling for specialty, teachers did not differ from nonteachers in patient-care volume or payer mix of the practice. Teachers noted a 30-minute (median) lengthening of their workday when a student was present, and 30% saw fewer patients per day when a student was in the practice. Only 9% of the teachers reported being paid for their teaching. More than 90% of both nonteachers and teachers believed that students should receive part of their education in community-based practices. CONCLUSIONS: Depending on specialty, 20% to 30% of community-based generalists teach medical students. Although teachers perceive that teaching lengthens their work day and may decrease productivity, the great majority of both teachers and nonteachers believe that community-based education is important.

Ambulatory Care↗
PubMed1998

Training pediatricians for the evolving generalist-specialist interface in the managed care era.

Managed care involves the linkage of service delivery and financing. One of the outgrowths of the rapid expansion of managed care over the past decade has been an increasing consensus that the generalist of the future will need to manage more of the patients traditionally cared for by subspecialists. Subspecialty education for pediatric residents becomes increasingly important as the role of the pediatric generalist enlarges to include independent outpatient management of some less complex but traditional subspecialty patients as well as collaborative management of more complex patients. To prepare for this role, a balanced exposure to subspecialty problems in outpatient as well as inpatient settings is required. At the same time, however, the growth of managed care has led to certain barriers for providing this enhanced training. This article describes the effects of managed care on the role and scope of the pediatric subspecialist as well as on educational strategies for coping with these changes while reshaping the roles of both generalists and subspecialists for maximal effectiveness in meeting the health care needs of children.

Academic Medical Centers↗
PubMed1998

Which medical school applicants will become generalists or rural-based physicians?

The hypotheses that data, available at the time when a medical school admission decision is made, can be used to predict generalist specialty choice and rural practice location were tested. Applicant data, available to admissions committee members at the University of Louisville in 1986 and 1987 about the classes of 1990 and 1991 respectively, were correlated with specialty choice and practice location in a retrospective cohort study. Data collected from 1994 to 1996 about the 1990 and 1991 graduates were used to develop a mathematical model to predict specialty choice and practice location using stepwise logistic regression. These models were more accurate in predicting which applicants would not select a generalist career (negative predictive value = 80.7%) than those who would (positive predictive value = 42.7%) and in predicting those who would not practice in a rural location (negative predictive value = 91.9%) than those who would (positive predictive value = 37.8%). We conclude that applicant data, available at the time admission decisions are made, are of limited value for identifying those who will eventually become generalist physicians or practice in a rural area. However, the data are useful for identifying those who will not.

Career Choice↗
PubMed2026

Species Distribution Models Support Distinct and Non-Random Climatic Constraints on Globally Distributed Generalist Fungi.

Fungi play essential roles in ecosystems as pathogens, mutualists, and ubiquitous decomposers. However, like many important microbes, the spatial distribution of species and natural populations remains poorly understood compared to plants and animals. Many fungi are described as global generalists because they occur across wide geographic areas, but it remains unclear how and if these species are constrained by climate or geographic barriers. In this study, we used Species Distribution Models to infer the global climatic suitability of three common and globally distributed fungi: Aspergillus flavus, Penicillium chrysogenum and Aspergillus fumigatus. Models were constructed using global occurrence data from the Global Biodiversity Information Facility and were trained with Bioclimatic variables from the WorldClim dataset. All species' models showed high prediction fit, with predicted occurrence concentrated in the temperate and subtropical regions and broadly structured patterns. Each species showed distinct predicted distributions, but they displayed considerable spatial overlap on a global scale. Together, these results demonstrate that even apparently globally occurring and generalist fungal species occupy climatically structured niches. This study highlights the utility of SDMs and it provides a framework for future studies integrating ecological, genomics and evolutionary perspectives among the difficult to assess geographically widespread and common fungi.

comparative biogeography↗
PubMed1999

Ascorbic and uric acid responses to xanthotoxin ingestion in a generalist and a specialist caterpillar

For herbivorous insects, dietary sources of low molecular weight non-enzymatic antioxidants, such as ascorbic acid, may influence performance in the presence of phototoxic plant constituents. We examined responses of Trichoplusia ni, a broad generalist, and Depressaria pastinacella, a specialist on furanocoumarin-containing plants, to variation in dietary ascorbic acid availability in the presence and absence of xanthotoxin, a phototoxic furanocoumarin. In T. ni, dietary ascorbic acid significantly increased levels of this compound in body tissues (approximately 7-fold, 5-fold, and 8-fold in hemolymph, gut, and fat body, respectively). In the presence of xanthotoxin, however, the amount of ascorbic acid accumulated significantly decreased. This decrease was not due to antifeedant effects of xanthotoxin and may instead have resulted from depletion of ascorbic acid due to its radical scavenging activity. In contrast, ascorbic acid levels in D. pastinacella were less affected by variation in dietary levels of either xanthotoxin or ascorbic acid, although uric acid, another potential water-soluble nonenzymatic antioxidant, increased in response to dietary ascorbic acid, as it did in T. ni. Thus, for generalists, such as T. ni, that lack specialized detoxification mechanisms against phototoxins such as furanocoumarins, dietary ascorbic acid may play an important role in antioxidant defense, and, for caterpillars in general, uric acid may also contribute to antioxidant defenses. Arch. Copyright 1999 Wiley-Liss, Inc.

Journal Article↗
PubMed2001

Is rheumatoid arthritis care more costly when provided by rheumatologists compared with generalists?

OBJECTIVE: Controversy surrounds the cost-effectiveness of rheumatologist care compared with generalist care for patients with rheumatoid arthritis (RA). Rheumatologists can provide 2 distinct types of care for RA patients: primary care and specialist care. We sought to examine the relationship between cost and type of care in a population-based cohort of patients with RA. METHODS: Data regarding specialty of care and use of health services (i.e., total direct medical costs, surgeries, radiographs, laboratory tests, hospital days) were collected from a community sample of 249 patients with RA (defined using the 1987 American College of Rheumatology diagnostic criteria) among Rochester, Minnesota residents > or =35 years of age. In a randomly selected subset of 99 of these RA patients, detailed information on all physician encounters was collected and categorized according to whether or not the care received constituted "primary care" according to the Institute of Medicine definition. Using these data, we evaluated the influence of type of care as well as specialty of provider on utilization. For these analyses, total direct costs included all inpatient and outpatient health care costs incurred by all local providers (excluding outpatient prescription drugs). RESULTS: The 249 patients with RA (mean age 64 years, 75% women) were followed up for a median of 5.4 years, while the subset of 99 RA patients (mean age 64 years, 77% women) were followed up for a median of 4.7 years. The overall median direct medical costs per person per year were $2,749 and $2,929 for the total cohort and for the subset of 99 patients, respectively. Generalized linear regression analyses (considering all visits of the 249 RA patients) revealed that after adjusting for demographics and disease characteristics, rheumatologist care (compared with nonrheumatologist care) was not associated with higher total direct medical costs (P = 0.85) or more hospital days (P = 0.35), but was associated with slightly more radiographs (P = 0.037) and significantly more laboratory tests (P < 0.0001). When considering only primary care, such care by rheumatologists was, again, not associated with higher total direct medical costs (P = 0.11) or more hospital days (P = 0.69) or more laboratory tests (P = 0.54), but was associated with slightly more radiographs (P = 0.035). CONCLUSION: Rheumatologist care is not more costly than generalist care for patients with RA. Important differences (especially in the use of laboratory tests) become apparent when the type of care provided as well as the specialty of the provider are considered in the analyses.

Adult↗
PubMed1994

Teaching and learning methods for new generalist physicians.

This paper describes teaching and learning methods that can be used to build the competencies needed by the generalist physician. Supervised patient care, problem-based learning, and ongoing feedback through standardized patients all have proven efficacy in several domains. Computer-based learning has much to offer as a supplement to clinical teaching. New learning experiences in continuous improvement promise to cover areas that are not often reached by traditional methods, especially those of cost-effectiveness and quality of care. The authors review each method's principles, relationship to generalist competencies, examples of effective applications, and challenges to successful implementation. Where possible, they summarize what is known about the relationships of learning and teaching methods to career choices in generalism.

Adult↗
PubMed1994

Strengthening academic generalist departments and divisions.

Academic departments of family medicine and divisions of general internal medicine and general pediatrics exist in the majority of medical schools in the United States and have important roles in generalist medical education. The major organizational issues facing these units concern institutional influence, faculty development, role in medical education, research productivity, financial stability, and clinical responsibilities. These issues must be understood in order for medical schools and teaching hospitals to achieve the societal goal of producing necessary generalist physicians.

Academic Medical Centers↗
PubMedDate not supplied

Faculty rewards for the generalist clinician-teacher.

Historically, medicine has regarded itself as a profession of great breadth, encompassing the total range of human activity: biological, behavioral, social and organizational. In the last several decades, however, it has become increasingly reductionist, fragmented, and specialized. Recent developments, as exemplified by the return of the generalist clinician-educator to the academic community, portend a reversal of this trend. Manifestations of a change in the orientation of medicine and medical education toward bolism and bumanism include a movement toward improved compensation for "cognitive" services, development of new promotion tracks for clinician-teachers, and increased support and recognition of applied clinical research. Generalist faculty are in a position to benefit from these trends, but obstacles remain; vigilism and activism are required to maintain momentum.

Ambulatory Care↗
PubMed2002

Intraguild interference and biocontrol effects of generalist predators in a winter wheat field.

Arable land typically harbours communities of polyphagous invertebrate natural enemies, among them numerous soil-surface dwelling predators such as ground beetles (Carabidae) and spiders (Lycosidae, Linyphiidae). Numbers of these predators were experimentally manipulated in a winter wheat field in order to study the predation impact of a generalist predator assemblage on herbivorous insects, the possible interferences among the predators concerned, and subsequent effects on wheat plant parameters. Removing ground beetles doubled numbers of Lycosidae indicative of intraguild interference between these two predator groups. Aphid densities were highest in carabid removal plots implying a substantial predation impact of ground beetles on the pest population. The predation impact of ground beetles was strongest earlier and disappeared later in the season. In mid-season, at intermediate aphid densities, the combined impact of carabid beetles and spiders appeared to be responsible for the reduction in aphid abundance. This result was probably due to a biomass effect rather than to a synergistic effect of the predator community. Thysanoptera decreased when spiders were removed (perhaps because spiders were preying on a predator of thrips), while Cicadellidae and Delphacidae showed no effect at all. The rise of aphid numbers in carabid removal plots corresponded to an increase in protein content of the wheat grains, while other plant parameters such as plant numbers and grain mass were not affected. In conclusion, this study provided field evidence for intraguild interference among generalist ground predators in arable land. Despite this interference the polyphagous predator community was able to depress numbers of aphids in winter wheat, a result cascading down to plant quality parameters.

Animals↗
PubMed2006

Is the cereal rust mite, Abacarus hystrix really a generalist? - Testing colonization performance on novel hosts.

The majority of eriophyoid mites are highly host specific and restricted to a narrow range of acceptable host plant species. The cereal rust mite, Abacarus hystrix was considered to be one of a few exceptions among them and has been found to be using a relatively wide host range. Since this species is a vagrant, inhabiting short-lived plants and aerially dispersing, it has commonly been considered to be a host generalist. Here the opposite hypothesis is tested, that host populations of A. hystrix are specialized on their local host plants and may represent host races. For this purpose, females from two host populations (quack grass, Agropyron repens and ryegrass, Lolium perenne) were transferred, and subsequently reared, on their normal (grass species from which females came from) and novel (other grass species) hosts. The female's fitness was assessed by survival and fecundity on the normal and novel host. Females of both populations had no success in the colonization of the novel host. They survived significantly better and had significantly higher fecundity on their normal host than on the novel one. These findings correspond with observations on host-dependent phenotype variability and host acceptance. The presence of locally specialized host populations in A. hystrix may be evidence for high host specificity among eriophyoids and the viruses they transmit. The main conclusion is that A. hystrix, which so far has been considered as a host generalist, in fact may be a complex species consisting of highly specialized host races.

Agropyron↗
PubMed2006

Mesostigmatid mites (Acari: Mesostigmata) on rainforest tree trunks: arboreal specialists, but substrate generalists?

Predatory mites (Acari: Mesostigmata) on tree trunks without significant epiphytic growth in a subtropical rainforest in Eastern Australia were assessed for habitat specificity (i.e. whether they are tree trunk specialists or occupying other habitats) and the influence of host tree and bark structure on their abundance, species richness and species composition. The trunks of nine tree species from eight plant families representing smooth, intermediate and rough bark textures were sampled using a knockdown insecticide spray. In total, 12 species or morphospecies of Mesostigmata (excluding Uropodina sensu stricto) were collected, most of which are undescribed. Comparison with collections from other habitats indicates that epicorticolous Mesostigmata are mainly represented by suspended soil dwellers (six species), secondarily by generalists (four species) and a bark specialist (one species). A typical ground-dwelling species was also found but was represented only by a single individual. In terms of abundance, 50.5% of individuals were suspended soil dwellers, 40.7% bark specialists, and 8.3% generalists. Host species and bark roughness had no significant effect on abundance or species richness. Furthermore, there was no clear effect on species composition. The distribution of the most frequently encountered species suggests that most mesostigmatid mites living on bark use many or most rainforest tree species, independent of bark roughness. These findings support the hypothesis that some epicorticolous Mesostigmata use tree trunks as 'highways' for dispersing between habitat patches, while others use it as a permanent habitat.

Animals↗
PubMed2006

Behavioral responses of a generalist mammalian folivore to the physiological constraints of a chemically defended diet.

Mammalian herbivores, particularly browsers and folivores, encounter and consume a range of plant chemical defenses [plant secondary metabolites (PSMs)] on a regular basis. The physiological regulation of PSM ingestion and the resulting behavioral responses of mammalian herbivores directly affect their feeding decisions and the subsequent foraging strategies that they adopt. Generalist mammalian herbivores are hypothesized to consume a generalized diet because of physiological limitations of their detoxification systems. The consumption of a generalized diet is proposed to enable toxin (PSM) dilution through the use of multiple detoxification pathways. We tested the predictions of the detoxification-limitation hypothesis by offering two chemically different plant species, Eucalyptus regnans and E. globulus, to a generalist mammalian folivore, the common brushtail possum (Trichosurus vulpecula), as single- and mixed-species diets. By feeding more efficiently, brushtail possums benefited more, through increased intake, on the mixed-species diet than on either of the single-species diets. We argue that frequently switching between chemically diverse foliage reduces the physiological constraints imposed by a PSM-rich diet and enables more efficient feeding. The behavioral responses of brushtail possums were consistent with the proposed physiological constraints of a chemically defended diet, offering support for predictions of the detoxification-limitation hypothesis. We suggest that feeding behavior of herbivores may be a useful indicator of the physiological constraints imposed by a chemically defended diet.

Animals↗
PubMed1983

Reverse consultations: the profiles of patients referred from subspecialists to generalists.

To determine the characteristics of patients referred by subspecialists to generalists, we compared 67 patients referred by three medical subspecialty clinics to the general internal medicine clinic to 162 randomly chosen patients who were retained by those clinics, with respect to the patients' need for a broad array of services. A trained abstractor reviewed the records for the prior year for patient characteristics indicating a need for broad-based care. The mean referred patient age was 53.7 yr compared to 46.2 yr in the retained group (p = 0.001); 33% of referred patients, as compared to 20% of those retained, had references to psychosocial problems in the physician notes (p = 0.03). Referred patients had 2.34 diagnoses outside of the subspecialty, compared to 1.27 for retained patients (p = 0.001). Referred patients had more recorded complaints outside of the subspecialty, 1.18 vs 0.71, (p = 0.02). Referred patients also had significantly more total clinic visits and visited twice as many different types of clinics in the past year (p = 0.001). There were no differences in payment method or insurance status. These findings suggest that university based subspecialists prefer to refer medically and psychosocially complex patients. If it is desirable that subspecialists value such patients more highly, changes in subspecialty training programs might be needed. If not, more generalists may be needed to care for such patients.

Adult↗