Generalist Practice Research Articles

William Pickles Lecture 2013: For they are born for another time.

The poet George Seferis wrote: ‘As pines keep the shape of the wind … so words guard the shape of man.’ 1 I want to dedicate this lecture to the memory of Helen Lester. Helen was wonderful in shaping her words. She will live on in our hearts for what she achieved, just as William Pickles has left a lasting legacy. From his country practice in Wensleydale and his interest in epidemiology he brought the values of primary care to an academic world where secondary care dominated. Half a century later, the secondary ethos still tends to rule in the university arena. I am the only GP on a Council of 34 medical school deans. I will argue that a readjusted balance, away from the dominant secondary care context of medical education, is needed to produce doctors fit for future health care. The honour of presenting this lecture led me to reflect on a mantra I have frequently used: ‘Do not confine children to your own learning for they were born in another time.’ (Hebrew proverb). A fundamental fact, often overlooked by educators, is that the world as viewed through the eyes of the young is inevitably different from ours. There is a strong and natural tendency to look back to the old, perhaps unsustainable, values of our own education. We struggle to look forward. Yet the different values of the new generations may equip them better for the challenges they will inevitably face. There is potential for GPs to engage much more overtly with undergraduate education, bringing our community-based generalist expertise to the fore and strengthening our presence and leadership. I have chosen to centre my reasoning on the definition of generalist practice framed by Joanne Reeve and colleagues: ‘Generalist practice is decision making which is person-focused, not disease-focused, …

Understanding the distinct experience of rural interprofessional collaboration in developing palliative care programs

Palliative care is one component of rural generalist practice that requires interprofessional collaboration (IPC) amongst practitioners. Previous research on developing rural palliative care has created a four-phase capacity development model that included interprofessional rural palliative care teams; however, the details of rural team dynamics had not been previously explored and defined. A growing body of literature has produced models for interprofessional collaborative practice and identified core competencies required by professionals to work within these contexts. An Ontario College of Family Physicians discussion paper identifies seven essential elements for successful IPC: responsibility and accountability, coordination, communication, cooperation, assertiveness, autonomy, and mutual trust and respect. Despite the fact that IPC may be well conceptualized in the literature, evidence to support the transferability of these elements into rural health care practice or rural palliative care practice is lacking. The purpose of this research is to bridge the knowledge gap that exists with respect to rural IPC, particularly in the context of developing rural palliative care. It examines the working operations of these teams and highlights the elements that are important to rural collaborative processes. For the purpose of this qualitative study, naturalistic and ethnographic research strategies were employed to understand the experience of rural IPC in the context of rural palliative care team development. Purposive sampling was used to recruit key informants as participants who were members of rural palliative care teams. The seven elements of interprofessional collaboration, as outline above, provided a preliminary analytic framework to begin exploring the data. Analysis progressed using a process of interpretive description to embrace new ideas and conceptualizations that emerged from the patterns and themes of the rural health providers' narratives. The questions of particular interest that guided this work were: What are the collaborative processes of a rural palliative care team? To what extent are the seven elements of IPC representative of rural teams' experiences? Are there any additional elements present when examining the experiences of rural teams? The analysis showed that the seven identified elements of IPC were very much integrated in rural teams' collaborative practice, and thus validated the applicability of these elements in a rural context. However, all seven elements were implemented with a rural twist: the distinctiveness of the rural environment was observed in each element. In addition, another element, specific to rural context, was observed, that being the 'automatic teams' of rural practitioners - the collaboration has been established informally and almost automatically between rural practitioners. This research contributes new knowledge about rural palliative care team work that can assist in implementing models for rural palliative care that apply accepted elements of collaborative practice in the rural context. Understanding the process of how rural teams form and continue to function will help further the current understanding of IPC in the context in which these professionals work.

Preparation for Social Service Leadership: Field Work and Virtual Organizations That Promote Critical Thinking in Administration Practice

This article examines how to prepare professional social workers for real-world nonprofit leadership roles. A pilot course assignment that incorporates a quasi-organization fieldwork simulation developed by the author is described. Development and application of critical thinking skills are reviewed, the course objective is explained, and methods and content that evolved during a three-semester trial are outlined. Student assignments and evaluation results indicate that a virtual asynchronous classroom experience is beneficial for students and faculty and that MSW administration students studying advanced generalist practice are an under-recognized potential source of nonprofit leadership.

Medical Nutrition Therapy in Adults with Chronic Kidney Disease: Integrating Evidence and Consensus into Practice for the Generalist Registered Dietitian Nutritionist

Chronic kidney disease is classified in stages 1 to 5 by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative depending on the level of renal function by glomerular filtration rate and, more recently, using further categorization depending on the level of glomerular filtration rate and albuminuria by the Kidney Disease Improving Global Outcomes initiative. Registered dietitian nutritionists can be reimbursed for medical nutrition therapy in chronic kidney disease stages 3 to 4 for specific clients under Center for Medicare and Medicaid Services coverage. This predialysis medical nutrition therapy counseling has been shown to both potentially delay progression to stage 5 (renal replacement therapy) and decrease first-year mortality after initiation of hemodialysis. The Joint Standards Task Force of the American Dietetic Association (now the Academy of Nutrition and Dietetics), the Renal Nutrition Dietetic Practice Group, and the National Kidney Foundation Council on Renal Nutrition collaboratively published 2009 Standards of Practice and Standards of Professional Performance for generalist, specialty, and advanced practice registered dietitian nutritionists in nephrology care. The purpose of this article is to provide an update on current recommendations for screening, diagnosis, and treatment of adults with chronic kidney disease for application in clinical practice for the generalist registered dietitian nutritionist using the evidence-based library of the Academy of Nutrition and Dietetics, published clinical practice guidelines (ie, National Kidney Foundation Council on Renal Nutrition, Renal Nutrition Dietetic Practice Group, Kidney Disease Outcomes Quality Initiative, and Kidney Disease Improving Global Outcomes), the Nutrition Care Process model, and peer-reviewed literature.

Stepping up: a nurse-led model of care for insulin initiation for people with type 2 diabetes

Most people with type 2 diabetes (T2D) have glycaemic levels outside of target. Insulin is effective in improving glycaemia and most people with T2D eventually need this. Despite this, transition to insulin therapy is often delayed in primary care. To develop a model of care (Stepping Up) for insulin initiation in routine diabetes care in Australian general practice. To evaluate the model for feasibility of integration within routine general practice care. Drawing on qualitative work and normalisation process theory, we developed a model of care that included clarification of roles, in-practice systems and simple clinical tools. The model was introduced in an educational and practice system change intervention for general practitioners (GPs) and practice nurses (PNs). Five practices (seven GPs and five PNs) and 18 patients formed the feasibility study. Evaluation at 3 and 12 months explored experiences of GPs, PNs and patients. Fourteen patients commenced insulin, with average HbA1c falling from 8.4% (68.3 mmol/mol) to 7.5% (58.5 mmol/mol) at 3 months. Qualitative evaluation highlighted how the model of care supported integration of the technical work of insulin initiation within ongoing generalist GP care. Ensuring peer support for patients and issues of clinical accountability and flexibility, managing time and resources were highlighted as important. The Stepping Up model allowed technical care to be embedded within generalist whole-person care, supported clinicians and practice system to overcome clinical inertia and supported patients to make the timely transition to insulin. Testing of the model's effectiveness is now underway.

Oral Histories and Service Learning to Promote Geriatric Competence, Comfort, and Career Interest

Gathering oral histories allows BSW students to learn and apply person-centered care principles through individualized social engagement with older adults. Thirty-three undergraduates enrolled in generalist practice took part in a semester long service-learning project gathering oral histories of older adults. A mixedmethods pre/post quasi-experimental design with a comparison group of BSW students engaged in service-learning in other settings evaluated the effects on student attainment of geriatric social work competencies, comfort engaging with older adults, and career interest. Relative to the comparison group, oral history students demonstrated statistically significant gains in values, assessment, intervention, and aging services geriatric competence. Competence related to values had the strongest effect size. Student comfort with older adults and career interest did not change. Although analysis of students’ critical reflections indicated that learning to communicate with cognitively impaired older adults was challenging, findings suggest that participant understanding of the aging process expanded.

The impact of workforce redesign policies on role boundaries in 'generalist' podiatry practice: expert views within the professional body.

BackgroundDemographic changes and a predicted rise in the prevalence of chronic illness have led to a range of health policies in the UK (and elsewhere) focused on workforce flexibility and extended roles for the allied health professions. Whilst much academic attention has been paid to extended specialised roles for allied health professionals such as podiatrists, little work has addressed the likely impact of these policy changes on non-specialist, ‘generalist’ podiatry practice. This study aimed to explore expert professional views on the impact of role flexibility on generalist podiatry practice.MethodsExpert podiatry practitioners drawn from within the professional body, the Society of Chiropodists and Podiatrists/College of Podiatry were recruited to 3 focus groups and 4 individual semi structured interviews and the data subject to a thematic analysis.ResultsThree key themes emerged, reflecting concerns about the future of generalist podiatry practice in the NHS, a perceived likelihood that generalist care will move inexorably towards private sector provision, and a growth in support worker grades undermining the position of generalist practice in the mainstream health division of labour. Up skilling generalist practitioners was viewed as the strongest defence against marginalisation.ConclusionsAn emphasis on enhanced and specialised roles in podiatry by NHS commissioners and profession alike may threaten the sustainability of generalist podiatry provision in the state funded NHS. Non-specialist general podiatry may increasingly become the province of the private sector.

Teaching Group Work in the BSW Generalist Social Work Curriculum: Core Content

In this article, nine considerations associated with social work practice with groups are identified and discussed. These range from the importance of mutual aid and the role of the group leader to multicultural competence and practice skills needed in the beginning, middle, and ending phases of group work. Group work is only one of four modalities that must be taught in the undergraduate practice sequence. Therefore, the nine considerations represent the essential content on group work for the generalist practice curriculum. The author assumes that this content can be presented in a 7-week time frame. In a companion article, the author presents teaching strategies and techniques that assist the instructor in conveying the principles for practice discussed in the present article.

The BSW Social Work Curriculum: Teaching Strategies, Case Material, and Assignments for Teaching Group Work

This article is a companion piece to another article appearing in this special edition of Social Work with Groups on group work content for the generalist practice curriculum. In this article, techniques that assist the instructor in presenting the material on group work in the classroom are identified. These techniques, which include case material and classroom exercises, also help students connect their field and classroom learning about group work. The activities discussed in this article derive from the core group work content discussed in the previous article.

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions

ObjectivesProvision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role.DesignQualitative study in General Practice.SettingUK primary care.Main outcome measuresA qualitative study – interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory.Design and settingQualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory.ParticipantsUK based GPs (interview and surveys); European GP trainees (focus groups).ResultsOur findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP.ConclusionsWe describe four areas for change: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

2013 Update in addiction medicine for the generalist.

Increasingly, patients with unhealthy alcohol and other drug use are being seen in primary care and other non-specialty addiction settings. Primary care providers are well positioned to screen, assess, and treat patients with alcohol and other drug use because this use, and substance use disorders, may contribute to a host of medical and mental health harms. We sought to identify and examine important recent advances in addiction medicine in the medical literature that have implications for the care of patients in primary care or other generalist settings. To accomplish this aim, we selected articles in the field of addiction medicine, critically appraised and summarized the manuscripts, and highlighted their implications for generalist practice. During an initial review, we identified articles through an electronic Medline search (limited to human studies and in English) using search terms for alcohol and other drugs of abuse published from January 2010 to January 2012. After this initial review, we searched for other literature in web-based or journal resources for potential articles of interest. From the list of articles identified in these initial reviews, each of the six authors independently selected articles for more intensive review and identified the ones they found to have a potential impact on generalist practice. The identified articles were then ranked by the number of authors who selected each article. Through a consensus process over 4 meetings, the authors reached agreement on the articles with implications for practice for generalist clinicians that warranted inclusion for discussion. The authors then grouped the articles into five categories: 1) screening and brief interventions in outpatient settings, 2) identification and management of substance use among inpatients, 3) medical complications of substance use, 4) use of pharmacotherapy for addiction treatment in primary care and its complications, and 5) integration of addiction treatment and medical care. The authors discuss each selected articles’ merits, limitations, conclusions, and implication to advancing addiction screening, assessment, and treatment of addiction in generalist physician practice environments.

Succeeding in Rural Mental Health Practice: Being Sensitive to Culture by Fitting in and Collaborating

Sustainable solutions to the access to mental health care problems are complex and must address both the availability of mental health care resources and the acceptability of those resources to consumers. The purpose of this study was to determine how to address the acceptability problem by learning from medical and mental health care providers what mental health therapists need to know to be successful in providing care in rural communities. Using a qualitative design, focus groups were conducted in three rural communities (<2,500) with medical and mental health care providers practicing in these communities. Data were analyzed using inductive qualitative methods. Results indicate that in addition to sound clinical skill, mental health therapists should (A) be sensitive to the culture of the rural community in which they are working and (B) practice in a way that accommodates to the care culture of the community. The latter includes spending time with patients commensurate with what is expected by other providers, engaging in generalist practice, and collaborating with local providers in patient care. An important implication of these results is that mental health care must be acceptable to both the residents of the community and the gatekeepers to health care.

Generalist solutions to complex problems: generating practice-based evidence - the example of managing multi-morbidity

BackgroundA growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare?DiscussionStrengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem.We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem.SummaryAnswers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.

Book Review: Developing Evidence-Based Generalist Practice Skills

Book Review: Developing Evidence-Based Generalist Practice Skills

The Queensland Health Rural Generalist Pathway: providing a medical workforce for the bush

Click here to hear an intoduction by the authorsIntroduction: Queensland Health's Rural Generalist Pathway is a supported career pathway for junior doctors to train in rural and remote medicine. The pathway joins evidence with policy to achieve professional recognition, credentialing, and industrial recognition.Methods: This article describes the principles underpinning the notion of rural generalism, the background to the establishment of the Rural Generalist Pathway in Queensland, Australia, how the pathway has been developed to meet the needs of Queensland's rural and remote communities, the implementation of the pathway, and the implications for other jurisdictions.Results: In 2007, 30 trainees commenced on the pathway, with total enrolment now of 182 in 2012. Trainees commence at the start of internship, completing their prevocational training component in postgraduate years 1 to 2. After prevocational certification they undertake advanced specialised training in a range of specialties, and then complete vocational training in a rural location, usually in their 4th to 5th postgraduate years. Trainees complete their general practice training through a Regional Training Provider, and achieve vocational registration by completion of appropriate fellowship assessment requirements. The pathway is managed by a geographically dispersed team of educators, clinicians and managers. The Rural Generalist team provide training and career advice, advocate for trainees and assist with negotiating posts. They map progress of trainees through the Vocational Indicative Planning process and arrange other educational activities including Rural Generalist workshops. Applications are often oversubscribed, with the intake growing to 41 in 2012, located at 10 intern training hospitals. In total 90 trainees have completed advanced specialised training as at the end of 2012.Conclusion: The Rural Generalist Pathway includes a challenging prevocational start to the career, the opportunity to specialise in a procedural skill or skills of interest and obtain general practice vocational training in a rural setting and appears to be proving an attractive choice for medical graduates seeking a challenging and varied career. Early evidence suggests that by recognizing and rewarding the worth of rural and remote practice, this strategy is creating its own supply line. From its initial roll-out in Queensland, rural generalist training continues to generate increased interest and enthusiasm across all Australian states and territories wishing to join this new wave of generalist practice. This new generation of health professionals for a new generation of services has the potential to provide the rural medical workforce the bush needs.Key words: Australia, generalism, pathway, Queensland, rural generalist, rural medical education, vocational training.

Psychiatrists and GPs: diagnostic decision making, personality profiles and attitudes toward depression and anxiety

The objective of this article is to explore diagnostic decision making around psychological symptoms presenting to general practitioners (GPs) and psychiatrists, identify attitudinal and personality factors of possible relevance in these decisions, and compare GPs and psychiatrists to help identify potential educational targets. GPs and psychiatrists attended separate peer-facilitated workshops in which two case presentations were discussed. Decision making was explored by structured questions embedded in the workshop, with responses recorded by electronic keypad technology. Participants completed demographic questionnaires and measures of personality and attitudes to depression. GPs and psychiatrists accorded emphasis to different elements of the history, and assigned different diagnoses based on the same set of symptoms. Both groups relied on non-pharmacological management for milder psychological symptoms; GPs were less likely to make a diagnosis of bipolar disorder. Traits of Extraversion and Agreeableness were associated with greater ease in treating depression. Differences in diagnostic decision making likely reflect the different contexts of specialist and generalist practice. Educational targets may include information about key symptoms to assist in diagnostic precision, but further information is needed to determine the best match between diagnostic processes, context and outcome. An awareness of the role of personality factors may help when designing education and support programs.

2012 Update in addiction medicine for the generalist.

This article presents an update on addiction-related medical literature for the calendar years 2010 and 2011, focusing on studies that have implications for generalist practice. We present articles pertaining to medical comorbidities and complications, prescription drug misuse among patients with chronic pain, screening and brief interventions (SBIs), and pharmacotherapy for addiction.

Hiring priorities for BSW/MSW programs in the United States: Informing doctoral programs about current needs

Summary This study was designed to identify the hiring needs of social work programs across the United States. The study used a national survey of social work programs, including closed questions for quantitative analysis and an open question for qualitative comments. Findings Of the 226 MSW and BSW programs participating in this study, 95% stated that they expected to hire additional faculty in the next 5 years. The vast majority reported plans to hire at the assistant professor level. Although a PhD is a preferred degree for many programs, 62% suggested they would consider a DSW as equivalent to a PhD. Respondents suggested the most important factors influencing hiring decisions would be the candidate’s interpersonal skills, refereed publications, filling a diversity need, and supporting social work ethics. The most commonly sought areas of expertise sought include generalist practice, research/evaluation, policy, community practice, and diversity. Applications This study has implications for doctoral programs and for social workers seeking post-graduate education in the United States. One of the most interesting findings was the expressed desire for candidates with practical and practice-oriented experience. Social work departments offering research-oriented PhD degrees may want to supplement their programs by providing courses and practical experiences that prepare graduates for teaching. Departments offering DSW degrees may design their programs to fill perceived gaps in qualifications among the current pool of candidates for tenure and non-tenure positions (e.g. teaching generalist social work, advanced clinical social work, and administration). Similarly, social workers wishing to pursue academic careers should consider which types of education and experience are in greatest need. Social workers seeking academic appointments should also note that the emphasis on teaching versus research varies across institutions.

Career choices and what influences Nepali medical students and young doctors: a cross-sectional study.

BackgroundNepal, as a nation with limited resources and a large number of poor people, needs far more well-trained, committed general practitioners. The aim of this study was to understand medical career choices and the factors that influence medical students’ and young doctors’ career choices in Nepal and to understand what would encourage them to work in rural areas as generalists.MethodsThis was a cross-sectional study of 1137 medical students (first and final year) and young doctors (interns and residents) from six medical colleges in Nepal who completed a voluntary questionnaire, with some also participating in structured focus groups – 170 first years, 77 final years and 80 graduates – with an additional 28, 44 and 49 written responses respectively.ResultsWithout selective admissions policies, 41.7% (464/1112) of respondents had a rural background – most significant in Year 1 students, males and in colleges outside of Kathmandu. Of the respondents, 569 (50.9%) had a specialty choice starting medical school – the greatest proportion in Year 1. Medicine (especially cardiology) and surgery (particularly among males) were most significant choices at all stages. Only five participants initially and four during their course chose general practice. There appears no interest in, recognition of, significant exposure to, or role models in general practice.Serving the sick, personal interest and social prestige were the most significant influencing factors – consistent across all groups. Course availability was also a factor. To attract doctors to work in rural areas most respondents affirmed the need for a good salary, infrastructure and facilities, scholarships and career development opportunities.ConclusionsChallenges include raising generalists’ profiles within the medical community, government and patient community; changing undergraduate curricula to include greater exposure to good models of rural generalist practice; and providing incentives and attractions for post-graduate training and service.

Urinary incontinence in older people: an overview

Lower urinary tracts symptoms (LUTS) and urinary incontinence (UI), defined as involuntary loss of urine, are very common in the general population and increase in prevalence in late life. All LUTS have a considerable impact on morbidity and quality of life. Urinary incontinence is seldom discussed by patients, many of whom delay seeking care. Despite increasing evidence for effective management, older people are frequently neither assessed nor treated. This article discusses the assessment and management of the main subtypes of incontinence likely to be encountered in generalist practice for both the physiologically fit and frail older person.