Collaboration in the preparation of the generalist physician

Collaborative efforts among health care professionals and institutions at all levels will be essential to the increased production of generalist physicians. There have been many successful collaborations in education and patient care among certifying boards, faculty, physicians in practice, specialists, generalists, and non-physician health professionals, as well as among the three generalist specialties. Recommended strategies to encourage collaboration in the preparation of generalist physicians include: creation of an institutional collaborative curriculum committee; design of a longitudinal curriculum on collaboration for physicians-in-training and other health professionals; implementation of collaborative patient care in ambulatory care teaching clinics; development of integrated systems of care that link inpatient, outpatient, and community-based health services; and education of physicians-in-training in these and other collaborative and co-practice models of patient care.     

Implementation issues in generalist education

Devising a strategy for the implementation of a generalist medical educational program can be aided by grouping the many issues to be addressed into developmental stages. In this way, problems can be anticipated and resources marshalled. Initially, leadership and institutional support for the program must be developed. Next, detailed financial, curricular, and site planning must be undertaken. Implementation of the program must contend with faculty, site, and trainee concerns while consolidating financial and institutional support. Finally, in institutionalizing the program, financing must be secured and ongoing evaluation should provide information necessary to regularly reassess the program and renew its goals.     

Innovative generalist programs Academic health care centers respond to the shortage of generalist physicians

Academic health care centers increasingly are exploring innovative ways to increase the supply of generalist physicians. The authors review successful innovations at representative academic health centers in the areas of recruitment and admissions, undergraduate medical education, residency training, and practice support. Lessons learned focus on those areas that have demonstrated improvements in the number and quality of physicians trained in family practice, general pediatrics, and general internal medicine. Successful recruitment of generalism-oriented applicants requires identification and tracking of rural, minority, and other special groups of students at the high school and college levels. Academic health care centers that provide early, sustained, community-based, ambulatory experiences for medical students and residents encourage trainees to maintain and choose generalist careers. Finally, academic health care centers that link with community providers and with state government encourage the retention of generalist physicians through continuing education and teaching networks.     

Preparing generalist physicians The organizational and policy context

A combination of financial, regulatory, and professional factors have led to a gradual but pronounced decline in generalist training and practice in the United States. This trend is likely to undergo dramatic reversal, however, as reflected by the diverse range of health care reform proposals incorporating incentives to promote generalist education and primary care practice. Considerable consensus has been reached by a number of professional organizations and public policy groups regarding the broad details of reform of generalist physician training, but key areas of controversy remain with important implications for academic medical centers. In addition, the generalist professional organizations, particularly those of family practice, general internal medicine, and general pediatrics, are being challenged to reconcile historic differences in the definitions and training of generalist competence. In this, the call for “retraining subspecialists” will both offer an opportunity and entail a risk. Finally, academic medical centers will need new organizational structures that can combine the distinctive intellectual traditions and the expertise of the generalist medical disciplines to develop new approaches to the education and practice of primary care.     

Does physician uncertainty affect patient satisfaction?

Physicians may choose one of several strategies when initially uncertain about making a specific therapeutic recommendation. The authors investigated how patients’ satisfaction is affected by disclosure of uncertainty and its attempted resolution during a clinical encounter. Three hundred and four patients awaiting appointments at a university hospital’s ambulatory medical clinic were randomized to view one of five videotapes (VTs) of a patient seeking advice about antimicrobial prophylaxis for a heart murmur. In VT-1 and VT-2, the physician disclosed no uncertainty and prescribed therapy. In VT-3, VT-4, and VT-5, the physician openly conveyed uncertainty but then: (VT-3) prescribed antibiotics without resolving his uncertainty; (VT-4) consulted a reference book with the patient present, then prescribed; or (VT-5) checked a computer with the patient present, then prescribed. Patients rated their satisfaction with the physician on a standardized questionnaire. Differences in satisfaction between the five VTs were significant (p=0.001), with the highest ratings found for VT-1 and VT-2, where no uncertainty was disclosed. The lowest ratings in satisfaction were found when the physician expressed but then ignored uncertainty (VT-3) or examined a textbook (VT-4). Global satisfaction was inversely and significantly correlated (r=−0.47) with the patients’ perception of uncertainty in the physician. The manner in which clinical uncertainty is disclosed to patients and then resolved by the physician appears to affect patients’ satisfaction. Received from the General Medicine Unit. Department of Medicine; and the Division of Behavioral and Psychosocial Medicine, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York. Dr. Johnson is now at the North Canton Medical Foundation, North Canton, Ohio. Supported by a grant from the Charles A. Dana Foundation. Presented at the tenth annual meeting of the Society for Research and Education in Primary Care Internal Medicine, San Diego, California, April 30, 1987.     

The future of capitation The physician role in managing change in practice

Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances which protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations, and engage patients and communities in discussions about resource allocation. As a payment model, capitation offers opportunities for primary care physicians to influence the future of health care by improving the management of resources at a local level.     

HIV primary care by the infectious disease physician in the United States - extending the continuum of care

Models of care for people living with HIV (PLWH) have varied over time due to long term survival, development of HIV-associated non-AIDS conditions, and HIV specific primary care guidelines that differ from those of the general population. The objectives of this study are to assess how often infectious disease (ID) physicians provide primary care for PLWH, assess their practice patterns and barriers in the provision of primary care. We used a 6-item survey electronically distributed to ID physician members of Emerging Infections Network (EIN). Of the 1248 active EIN members, 644 (52%) responded to the survey. Among the 644 respondents, 431 (67%) treated PLWH. Of these 431 responders, 326 (75%) acted as their primary care physicians. Responders who reported always/mostly performing a screening assessment as recommended per guidelines were: (1) Screening specific to HIV (tuberculosis 95%, genital chlamydia/gonorrhoea 77%, hepatitis C 67%, extra genital chlamydia/gonorrhoea 47%, baseline anal PAP smear for women 36% and men 34%); (2) Primary care related screening (fasting lipids 95%, colonoscopy 95%, mammogram 90%, cervical PAP smears 88%, depression 57%, osteoporosis in postmenopausal women 55% and men >50 yrs 33%). Respondents who worked in university hospitals, had <5 years of ID experience, and those who cared for more PLWH were most likely to provide primary care to all or most of their patients. Common barriers reported include: refusal by patient (72%), non-adherence to HIV medications (43%), other health priorities (44%), time constraints during clinic visit (43%) and financial/insurance limitations (40%). Most ID physicians act as primary care providers for their HIV infected patients especially if they are recent ID graduates and work in university hospitals. Current screening rates are suboptimal. Interventions to increase screening practices and to decrease barriers are urgently needed to address the needs of the aging HIV population in the United States.     

When the physician leaves the patient

OBJECTIVE: To identify independent predictors of patients’ satisfaction with transfer of their care from a departing to a new resident physician. DESIGN: A self-administered questionnaire completed by consecutive patients following up after transfer of their care, and by a randomly selected 50% of patients not returning within three months after transfer. SETTING: An internal medicine clinic in a teaching hospital. PATIENTS: Questionnaires were completed by 376 patients: 237 returning to clinic and 139 (91%) of 152 randomly selected patients who had not returned. Mean age of the patients was 65 years, 52% were men, and they had come to the clinic for a median of four years. RESULTS: 57% of the patients were satisfied with the transfer process, 25% were neutral, and 18% expressed frank dissatisfaction. Of nine variables significantly associated with satisfaction by univariate analysis, stepwise multiple regression identified five independent predictors. Personal notification of the patient by the departing physician was the most powerful determinant, explaining 41% of the variability in satisfaction. Other predictors were whether patients believed their physicians had done everything possible to facilitate transfer, whether the departing physician had provided opportunity for discussion of the transfer, whether this discussion was considered sufficient, and patients’ impressions of the institution. CONCLUSIONS: Most of the predictors identified can be influenced by physician behavior, suggesting that physicians should personally notify patients of their departure and provide an opportunity for discussion. This could significantly improve patient satisfaction with the transfer process and, as previous studies suggest, translate into greater compliance with medications and follow-up. Received from the Departments of Medicine, Walter Reed Army Medical Center, Washington, DC, and the Uniformed Services University of the Health Sciences, Bethesda, Maryland. Presented in abstract form at the Mid-Atlantic Region Society of General Internal Medicine Meeting, Bethesda, Maryland, February 28, 1992; and at the American College of Physicians Annual Session, Washington, DC, April 1, 1993. The opinions or assertions contained herein are the private views of the authors and are not to be considered as official or as reflecting the view of the Department of the Army or the Department of Defense.     

Barriers to Patient-Clinician Collaboration in Asthma Management: The Patient Experience

Objective. To describe what adult patients with asthma report about their experiences with their own self-management behavior and working with their clinicians to control asthma. Methods. The study sample consisted of 104 patients with persistent asthma participating in a clinical trial on asthma monitoring. All subjects were seen by primary care clinicians of a large, academic medical center. This qualitative post hoc analysis examined the views of adults with asthma about their asthma-related health care. Patients attended monthly visits as part of their study participation, during which data were derived from semistructured interviews. All patients included in this analysis participated in the study for 1 year. At the end of study participation, patients were asked to complete an evaluation of their clinician's communication behavior. All study clinicians were also asked to complete a self-evaluation of their own communication behavior. Results. Five major themes of barriers to successful self-management were identified, including personal constraints, social constraints, communication failures, medication issues, and health care system barriers to collaboration with their clinicians. Patients most frequently reported lack of communication surrounding issues relating to day-to-day management of asthma (31%) and home management of asthma (24%). Clinicians generally rated themselves well for consistency in showing nonverbal attentiveness (89%) and maintaining interactive conversations (93%). However, only 30% of clinicians reported consistency in helping patients make decisions about asthma management and only 33% of clinicians reported consistency in tailoring medication schedules to the patient's routines. Conclusion. These findings emphasize the difficulties of establishing and maintaining a therapeutic partnership between patients and clinicians. The results underscore the need for system-wide interventions that promote the success of a therapeutic patient-clinician relationship in order to achieve long-term success in chronic disease management.     

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 holism and humanism 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.     

Impact assessment of a primary care physician counseling program for youth population

This study aimed to investigate the impact of implementing a primary care physician (PCP) counseling program for the youth population with healthcare needs. This quasi-experimental study used a nonequivalent control group pretest-posttest design, and was conducted at Salim Health Innovation Clinic in Seoul between February and October 2019 comprising 46 participating youths (intervention group) and 48 nonparticipating youths (control group). After 6 months of implementation, drinking (alcohol use control) decreased significantly in the intervention group (0.84 points). There was a significant difference in the anxiety level with a decrease of 2.86 and 0.65 points in the intervention and control groups (P = .011) respectively. There was also a significant difference in the health responsibility domain (P = .04). Moreover, a significant difference in self-efficacy level was found with a mean increase of 0.18 and 0.16 points in the intervention and control groups (P = .001), respectively. The youth population is more prone to neglect self-care due to poor physical and mental health status and no hope for the future because of a lack of jobs and rising housing prices. The program reinforces health-promoting behavior for managing stress and practicing eating high-quality meals, regular exercise, and regular health screening, which can help implement continuous and effective healthcare.     

Patient and physician characteristics associated with erythropoiesis-stimulating agent use in patients with myelodysplastic syndromes

Patient and physician characteristics associated with use of erythropoiesis-stimulating agents in myelodysplastic syndrome patients have not yet been described. Myelodysplastic syndrome patients diagnosed from 2001 to 2005 were identified from the Surveillance Epidemiology and End Results-Medicare database. Multivariate regressions examined the association between patient and physician characteristics and the probability of receiving any erythropoiesis-stimulating agents, and of receiving therapeutic-length (≥ 8 week) treatment episodes. Among the 6,588 myelodysplastic syndrome patients studied, 65% received erythropoiesis-stimulating agents. Use of erythropoiesis-stimulating agents was lower for blacks compared to whites (OR 0.78; 95% CI:0.61-0.99), single persons compared to married (OR 0.77; 95% CI:0.62-0.97), Medicaid recipients (OR 0.66; 95% CI:0.55-0.79), and those living in census tracts with lower educational attainment. Patients who did not consult a hematology-oncology specialist were less likely to receive erythropoiesis-stimulating agents. Specialist access, financial resources and mobility are key determinants of receipt of erythropoiesis-stimulating agents among myelodysplastic syndrome patients.     

Patient and physician satisfaction with a telephone-based anticoagulation service

OBJECTIVES: To compare the satisfaction and knowledge of patients who have their warfarin managed by their physician or by a multidisciplinary, telephone-based anticoagulation service (ACS) and to assess referring physicians' satisfaction with the ACS. DESIGN AND PARTICIPANTS: We surveyed 300 patients taking warfarin (mean age 73 years): 150 at health centers randomized to have access to an ACS, and 150 at control health centers without ACS access. We also surveyed 17 physicians who refer patients to the ACS. SETTING: Eight outpatient health centers in Missouri and Southern Illinois. MEASUREMENTS: We asked patients about the timeliness of international normalized ratio (INR) monitoring, perceived safety of warfarin, overall satisfaction with their warfarin management, and knowledge of what a high INR meant. We asked physicians at ACS-available health centers how many minutes they saved per INR by referring patients to the ACS, their satisfaction with the ACS, and their willingness to recommend the ACS to a colleague. MAIN RESULTS: As compared with patients at control health centers, patients at ACS-available health centers were more satisfied with the timeliness of getting blood test results (mean 4.31 vs 4.03, P =.02), were more likely to know what a safe INR value was (45% vs 15%, P =.001), and felt safer taking warfarin (mean 5.7 vs 5.2, P =.04). Physicians reported that using the ACS saved, on average, four minutes of their time and 13 minutes of their staff's time, per INR. All physicians recommended use of the ACS to a colleague and were highly satisfied with the ACS. CONCLUSIONS: A telephone-based ACS can be endorsed by primary-care physicians and improve patients' satisfaction with and knowledge about their antithrombotic therapy.     

Interprofessional student teams augmenting service provision in residential aged care

The aim of this study was to determine the usefulness of student‐led interprofessional consultations within residential aged care in augmenting patient care and enhancing student education. Volunteer fourth and final year health‐care students conducted interprofessional consultations. In a mixed methods design, residents' health‐care changes and perspectives were collected prospectively, and student and educator perceptions were measured by survey and interview. Sixteen aged care residents were consulted by interprofessional teams. Students identified two new health issues and proposed 17 recommendations for referrals and five changes to medication management. At six‐weeks follow‐up, two recommendations had been acted upon clinically, and two medication changes had been implemented. Reasons for the low uptake of recommendations were determined. Residents, students and educators reported high levels of satisfaction. Residential care facilities offer a useful interprofessional learning environment. Student consultations are positively regarded by patients, students and educators and may augment existing health services.     

A scoping review of patient-led teaching of health professions students

Patients with chronic health conditions may become experts in their own conditions. Thus, utilising patients as teachers, with autonomy over taught content, may better prepare students to deliver patient-centred care. A scoping review following Arksey and O'Malley and Joanna Briggs Institute framework was performed. A total of 2162 articles were identified and 28 unique studies were included. Patient teacher programmes range from single, short 1- to 2-h tutorials to longitudinal community-based programmes. These programmes are mutually beneficial for students, improving awareness of all patient-centred domains, and patients feel empowered by their roles in education.     

Deciphering the physician note

Objective information about legibility of physician handwriting is scant. This retrospective chart review compared handwritten general medicine clinic chart notes from internal medicine faculty and housestaff with their typed counterparts. The written counterparts took 11 seconds (46%) longer to read and 5 seconds (11%) longer to answer comprehension questions. The authors’ comprehension measure (developed specifically for ambulatory clinic notes) was only slightly higher for typed notes. The legibility of physician handwriting is not as dismal as assumed; physicians can effectively communicate on paper. Presented at the Southern Society of General Internal Medicine Winter Meeting, February 1, 1991, New Orleans, Louisiana. Supported in part by grant D28 PE-55009 from the Bureau of Health Professions, Health Resources, and Services Administration, and by Institutional NRSA award PHS T32 PE15001 from the National Institutes of Health. Dr. Dittus was partially supported by an American College of Physicians’ Teaching and Research Scholar Award.