Revising the definition of the generalist physician.

Although there has been growing recognition of the important role of generalist physicians in the United States, there has been insufficient discussion of who the generalists are and how their role is defined. Traditionally, generalists have been defined by their specialty, with physicians in family medicine, general internal medicine, and general pediatrics considered generalists. But this approach may not sufficiently recognize the specific competencies and therefore the specific training required of generalists. A new definition is based on the functional requirements of generalist practice and the central role that generalist physicians will play in comprehensive care. This definition can be used, first, to assure that medical education, both fundamental and continuing, provides generalists with these needed competencies and, second, to judge claims among different categories of physicians that they should be considered generalists.

Comparing medical school graduates who perform poorly in residency with graduates who perform well.

BACKGROUND: Most medical school graduates perform well as residents. However, the authors' annual surveys have shown that a few graduates from each class at their school fail to meet residency directors' expectations. METHOD: The medical school records of the 20 of the 153 graduates from the class of 1983 at the University of California, San Francisco, School of Medicine who received poor evaluations from their residency directors in the first and/or second year of residency were compared with the records of 20 of their best-received classmates. The poorly received graduates did not necessarily receive poor numerical ratings of their knowledge, skills, or overall performances, but they did receive negative or ambivalent responses to the following question: "Knowing what you now know about this resident, would select him or her again? Please explain." The two groups of graduates were matched for sex, racial-ethnic identification, and residency discipline. RESULTS: The groups were quite similar with respect to qualifications for admission to medical school, overall academic achievement, and performance on standardized national examinations. There were minor differences in performances on clinical clerkships. CONCLUSION: As indicated by residency directors' ratings and comments, most of the poorly received graduates' problems during residency appear to have been personal and motivational rather than skills- or knowledge-related. With but few exceptions, the medical school records contained little evidence that might have predicted the graduates' poor reception as residents.

Changes in gastrointestinal, pancreatic, biliary, and hepatic function with aging.

The understanding of "normal" aging of the gastrointestinal tract, pancreas, and hepatobiliary system is confounded by the difficulty in identifying healthy elderly subjects for study. There appear to be predictable changes in gastric secretion and emptying, intestinal and pancreatic morphology, colorectal motility, and hepatic mass and blood flow with aging. However, the functional significance of these changes is variable. Further investigations will be necessary to resolve currently conflicting data, and validation of animal models of aging will enhance future research into these areas.

Specialty choices at one medical school: recent trends and analysis of predictive factors.

Recent reports have raised the concern that personal care specialties, especially primary care specialties, are attracting fewer medical school graduates. In the present study, the authors evaluated the proportions of University of California, San Francisco (UCSF), medical school graduates entering personal care specialties and technology-oriented specialties from 1982 through 1988 and found no significant trend away from personal care specialties such as internal medicine, family practice, pediatrics, and psychiatry during these years. For the graduating class of 1988, admissions and questionnaire data were used to evaluate the importance of pre-admission, medical school, and postgraduate factors as determinants of specialty choice. The group entering personal care specialties (66% of all 1988 graduates) was significantly older and included more women and fewer minority students than the group entering technology-oriented specialties. Students rated income and lifestyle factors as being less important determinants of specialty choice than are medical school experiences and intrinsic qualities of the chosen specialties. However, compared with the students who entered personal care specialties, those who chose technology-oriented specialties over an alternate choice in personal care rated as significantly more important the opportunity to do procedures (p less than .001), income (p less than .005), the lesser degree of diagnostic uncertainty (p less than .005), and the rejected specialty's allowing less time for family (p less than .005) and for other interests (p less than .008). Exposure to acquired immunodeficiency syndrome and loan indebtedness were rated the least significant influences on specialty choice.(ABSTRACT TRUNCATED AT 250 WORDS)

Multifocal abnormalities of the gastrointestinal tract in AIDS.

On review of 63 barium sulfate examinations in 44 patients with acquired immunodeficiency syndrome (AIDS), 61% of the 23 single-contrast examinations and 98% of the 40 double-contrast examinations were abnormal. Abnormalities involved all areas of the gastrointestinal (GI) tract and covered a wide spectrum of findings including thickened folds, nodularity, increased secretions, superficial erosions, ulcerations, plaque formation, and tumor mass. Abnormalities, when present, were most commonly multifocal (three or more sites) on upper GI study (64%) and barium enema (69%). Thirty-eight patients (86%) had at least one abnormal study; 27 of these patients had multifocal disease in either the upper or lower tract separately or combined. The most common site of abnormality was the duodenum on upper GI study and the sigmoid colon on barium enema. In 27 cases the radiographic abnormalities could be specifically correlated with a malignancy or an opportunistic infection by endoscopy, colonoscopy, culture, biopsy, or autopsy. Multifocal disease of the upper and/or lower GI tract, especially when the duodenum is involved, should suggest AIDS even in patients not thought to be at high risk for the disease.

Gastrointestinal Kaposi's sarcoma in patients with acquired immunodeficiency syndrome. Endoscopic and autopsy findings.

Homosexual men with acquired immunodeficiency syndrome and Kaposi's sarcoma (KS) have been studied to define the extent of gastrointestinal KS. In 50 patients examined by both upper endoscopy and flexible fiberoptic sigmoidoscopy, 20 (40%) had visible lesions consistent with KS. Ten patients (20%) had upper and lower tract involvement, 6 (12%) patients had upper tract involvement alone, and 4 (8%) had lower tract disease alone. Only 23% of endoscopic biopsies of KS lesions were positive for KS. Gastrointestinal KS was not more frequent in patients with nodal KS (41%) than in patients with skin KS (50%). No clinical sequelae of gastrointestinal KS lesions were seen. Mortality was significantly greater in those patients with endoscopic evidence of gastrointestinal KS. Postmortem examination of 13 men with KS and acquired immunodeficiency syndrome revealed abdominal visceral involvement in 10 patients (77%). Antemortem endoscopic findings correlated with subsequent autopsy data in 5 patients. Our findings suggest that visceral involvement, though rarely symptomatic, may be associated with a poorer prognosis.