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).

Effect of physician profiling on utilization. Meta-analysis of randomized clinical trials.

OBJECTIVES: An American Medical Association survey reported that more than half of physicians are subjects of either clinical or economic profiling. This multilevel meta-analysis was designed to assess the clinical effect of peer-comparison feedback intervention (profiles) in changing practice patterns. METHODS: Systematic computerized and manual searches were combined to retrieve articles on randomized controlled clinical trials testing profiling reports. Eligible studies were randomized, controlled clinical trials that tested peer-comparison feedback intervention and measured utilization of clinical procedures. To use all available information, data were abstracted and analyzed on three levels: (1) direction of effects, (2) p value fro the statistical comparison, and (3) odds ratio (OR). MAIN RESULTS: In the 12 eligible trials, 553 physicians were profiled. The test result was p < .05 for the vote-counting sign test of 12 studies (level 1) and p < .05 for the z-transformation test of 8 studies (level 2). There were 5 trials included in the OR analysis (level 3). The primary effect variable in two of the 5 trials had a nonsignificant OR. However, the overall OR calculated by the Mantel-Haenszel method was significant (1.091, confidence interval: 1.045 to 1.136). CONCLUSIONS: Profiling has a statistically significant, but minimal effect on the utilization of clinical procedures. The results of this study indicate a need for controlled clinical evaluations before subjecting large numbers of physicians to utilization management interventions.

The case for a biological component in family practice behavioral science research.

This paper presents some of the reasoning behind the author's belief that it is important for academic family physicians to do research. The research process is compared to the process of clinical care, and significant analogies are pointed out. The argument then is presented to support the author's contention that it is time for family physicians to develop a research capability in selected aspects of the biological sciences in addition to the growing research activity in the social, behavioral, and clinical sciences which characterizes family medicine today. Reasons are given for considering the neurosciences the proper field in which such work should begin.

The virtue of unconventional research.

This address develops an historical approach to unconventional research in medicine. Such research is predominantly but not exclusively non-biological in character. Earlier examples of unconventional research are given, and these then are related to examples chosen from recent work dealing with patient function as an outcome of medical and nursing care. The major argument made is that it is important for unconventional research to continue.

Ethical aspects of the physician surplus: implications for family practice.

Higher costs, increasing technology, and more physicians are the three predominant influences facing medicine today. These three forces in turn present three groups of ethical issues for physicians: competition and changed fiscal incentives, effects of organized practice on autonomy and confidentiality, and the problems of the interface between primary and consultant physicians. Family physicians must learn to adapt their practices in ethical ways to the rapid changes that are occurring. Thoughtful insight is essential to the process.

Teaching clinical medicine in the ambulatory setting. An idea whose time may have finally come.

A resurgence of general interest in teaching clinical medicine in ambulatory-care settings has occurred for several reasons, including changes in the case mix in teaching hospitals, the new responsibilities of house officers and attending physicians brought about by the current payment systems for health care, the increased expectations of patients that medical care will be "personal," the progressive limitations imposed on the education of medical students by the shorter lengths of stay sought by hospitals under the diagnosis-related-groups system of payment, and the growing need for well-trained primary care physicians that has resulted from the increase in medical care organizations. In this paper, I review earlier attempts to emphasize ambulatory care, to identify the pitfalls that new efforts in this direction should avoid. I also compare inpatient and ambulatory-care teaching to provide a basis for understanding the educational goals that can be achieved more easily in each setting. In addition, I suggest major changes in the flow and use of clinical-practice funds and hospital payments so that they can become possible sources of the financing and organization of an expanded effort to teach clinical medicine in ambulatory-care settings.

The research environment in family practice.

Both the place of family practice in academic medicine and the intellectual underpinning of the specialty itself are thought by many to depend on the development of successful research programs in academic departments of family medicine. Yet many believe less research than desired is being done in such departments, even by faculty trained in research. To gain additional information on this important subject, a survey was conducted of the departmental research experiences of 42 graduates of the several Robert Wood Johnson Foundation Family Practice Academic Fellowship Programs who had had the opportunity for at least one year of faculty experience. The responses indicate that the majority of such graduates spend 20 percent or less of their time in research, that most perceive administrative duties as interfering with research, that a minority have budgeted research time, and few have departmental research funds. Despite these obstacles, those who do research publish with surprising frequency, about one paper per fellow per year. Several ways are presented to improve the research environment in departments of family practice and to lead to even more productive, secure research activities of these and other family practice faculty.

The Health Services Research Labor Force in the United States.

In 1978, the Panel on Health Services Research Training of the Committee on a Study of National Needs for Biomedical and Behavioral Research Personnel surveyed former health services research trainees and principal investigators to get information about the supply, employment, research, and teaching activities of people in these two groups. The survey shows that federal support for the training of health services research personnel has generated a cadre of investigators who remain active in health services research. Former trainees represent a cohort of largely younger investigators who are doing research of a type once done by older principal investigators who today engage in more administration and do less research. Most health services researchers are employed in academic settings and do research in their field.

An effect of organization of medical care upon health: manpower distribution.

Data are presented from the Medical Care Group of Washington University and from several other organized medical care settings responsible for prepaid enrollees. As few as 8 per cent of visit may be made to specialists under systems which are organized to emphazide primary care. Further, the proportions of primary care and specialty visits vary inversely weith the "strictness" of this organization. Those groups which employ family physicians have a higher proportion of primary care physicians than do those which employ general intermists and pediatricans, or than exist in the medical care system at large. The data suggest strongly that the organization of medical care, as well as the training of personnel employed has a major influence upon the types of health manpower needed. Future research in this area is urgent, but even the currently available data have important implications for health manpower policy.