Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative.

The Generalist Physician Initiative (GPI) was created by The Robert Wood Johnson Foundation to help medical schools increase the number of predoctoral and residency graduates entering generalist careers. The underlying assumption of the GPI is that more medical graduates will become generalists if schools select candidates whose personal characteristics are compatible with generalist careers and if schools provide for them an educational environment that values generalist careers in the same manner it has valued specialist careers. In essence, the GPI is helping schools modify the culture in which medical education occurs so that they may increase their production of generalists. Fourteen grants for six years of support were made to 16 U.S. medical schools in 1994. These schools are developing institution-wide efforts that span the continuum from the recruitment and selection of students through their medical school and residency education to their entry into practice, and include support of the practice. Most schools have developed external partners (e.g., state legislatures, managed care organizations, area health education centers) to assist in achieving their goals. The project is now (1997) at its halfway mark. This article describes the conceptual bases for the program (e.g., changes in admission criteria to favor applicants oriented to generalism), identifies common approaches to intervention chosen by the participating schools (e.g., establishing longitudinal, generalist-oriented clinical experiences throughout the four years of medical school), and explores issues being faced by the schools as they implement change (e.g., difficulties in decentralizing clinical education to include community physicians as teachers and role models).

Task Force 4: The relationship between cardiovascular specialists and generalists.

1. An imbalance between generalists and cardiovascular subspecialists exists that will require decades to correct. We question the validity of the 50:50 generalist/specialist ratio in view of current practice patterns for cardiology. 2. There has been a large increase in the number of cardiovascular specialists in the past 30 years that will continue if training programs remain at their current size. 3. Cardiovascular specialists provide a substantial amount of inpatient care, care to older patients and care to those with cardiovascular symptoms, although generalists actually provide the majority of office-based cardiovascular care. 4. A significant portion of cardiovascular specialist care can be classified as comprehensive care to patients with and without cardiovascular disease. 5. Most generalists and cardiovascular specialists do not perceive a need for additional cardiovascular specialists. 6. Many providers perform cardiovascular procedures at levels below the recommended threshold for maintenance of clinical competence. 7. Managed care may result in a reduced demand for cardiovascular specialists. 8. If cardiovascular specialists provide general care, it may not be assumed that previous training prepares them for generalist practice. 9. The appropriate boundaries of cardiovascular care between generalists and cardiovascular specialists are indistinct. They are defined somewhat by the training programs from which the generalists graduate. 10. Many generalists have deficiencies in basic skills in clinical cardiology. 11. Desirable interactions between generalists and cardiovascular specialists involve referral of patients in both directions to the provider who can give care to a given patient, at a given time, with the best outcome and lowest cost.(ABSTRACT TRUNCATED AT 250 WORDS)

Success strategies for departments of family medicine.

Strong departments of family medicine in academic medical centers help assure the future scope and quality of family practice patient care, the ongoing evolution of family medicine as a scholarly discipline, and a continued flow of qualified medical school graduates into family practice residency programs and eventually into practice. This report presents key strategies of six successful departments of family medicine and describes the methods and skills considered important by the leaders of these departments. Common themes that emerge are (1) recruit and mentor the best faculty, (2) build a reputation for clinical excellence of faculty and residents, (3) become part of schoolwide curriculum activities, (4) establish a scholarly presence, and (5) develop networks of support.

The financial impact of a nursing home practice on an academic medical center.

This study reports the economic contributions of nursing home practice to an academic department of family practice as well as the fiscal impact of referrals from nursing home practice on an academic medical center. Payment to primary physician faculty for nursing home service did not fully compensate for faculty effort. Nevertheless, these services did result in significant revenues to consulting physicians and the University Hospital. In aggregate, an average nursing home visit was associated with $33 in charges for the visit by the primary physician, $15 for additional primary care services in the clinic and hospital, $72 for services by consulting physicians, and $307 in charges by the University Hospital. The average nursing home patient provided $3,744 in charges and $2,403 in income to the academic medical center per year, with $1,813 going to the hospital and $331 to consulting physicians. Even though primary care is not well reimbursed, a relatively small number of patients have the capacity to create substantial income for consulting physicians and the hospital. The study does not address whether these nursing home referrals to the hospital utilized disproportionately high hospital resources.

Financing graduate medical education in family medicine.

Family practice residency programs differ fiscally from residency programs in most other specialties because they have limited income-generating potential. The present review demonstrates that the typical family practice residency program has been fiscally solvent as a result of receiving approximately one-third of its income from state and federal appropriations. The level of such support plateaued in the 1980s and programs have not continued to expand despite an ongoing shortage of family physicians. Today, declining Medicare payments to hospitals threaten hospitals' contributions to family practice residency programs. The ability of family practice residency programs to meet the continuing need for family physicians will depend upon the development of specific state and federal policies that provide fiscal incentives to maintain and expand family practice residencies.

From the president: STFM. Reflections on generalism in medicine.

Issues concerning the role of the generalist in medicine are not new. Indeed, we live in a specialty-oriented society which tends to define generalism in terms of specialism. Yet, as Gotshalk states, "Where it (the general aspect of a problem) is not satisfactorily handled, all specialization is an improvisation of temporary stopgaps on the way to ever recurrent crises."

Social supports and stress as predictors of illness.

The incidence and pattern of self-reported illness were studied over a six-month period in panels of 292 women and 188 men categorized by their experience of stressful life changes and their perceived supportive relationships. Men and women with more than average stressful changes had a risk of illness 1.6 and 1.8 times that reported by those with below-average changes. Analysis of the interaction of stressful changes with social supports showed that women with a combination of high changes and low supports experienced 2.5 times the rate of illness as those with low changes and high supports. This interaction was not found for men. A monthly rating of perceived life stress was correlated with subsequently recalled life changes for both men and women. The findings for women are consistent with the hypothesis that the interaction of stress with degree of social support is an important predictor of illness experience.

Practice location as a function of medical school and residency location: implications for resident selection.

Numerous studies have documented an association between the state in which a physician practices and prior education in that state. To determine whether this relationship exists for recent family practice residency graduates, 95 randomly selected programs in which residents completed training in 1979 were surveyed to obtain information regarding practice location and medical school location for their graduates. Seventy-nine percent of physicians completing residency and medical school in the same state also practiced in that state. Of those completing residency in a state other than that of their medical school, 43 percent stayed in the state of their residency to practice, and 22 percent returned to the state of their medical school. An analysis of the impact that a policy restricting house staff positions to in-state students would have on physician supply for the state reveals that only about 10 percent more physicians would be expected to start practice in a state if such a policy were implemented.

Academic and personal predictors of clinical success in medical school.

Admissions interview data and college academic credentials of five classes of University of Missouri-Columbia medical students were evaluated as possible predictors of clinical success. Those students who were judged by admissions interviewers to have high levels of maturity, nonacademic achievement motivation or rapport were approximately two to three times as likely to receive outstanding internship recommendations as those without such personal characteristics. Under-graduate grade-point average had a smaller but nevertheless significant relationship with clinical success as measured by internship letters. These data suggest that additional emphasis during selection upon applicants' personal characteristics would have enhanced the clinical success of these students.

Academic and personal characteristics as predictors of clinical success in medical school.

Interviewer ratings of personal characteristics such as maturity correlated with clinical success, and were more important in determining clinical success than were conventional cognitive variables of grade point average or MCAT scores for five classes of University of Missouri-Columbia medical students.