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Knowledge, patterns of care, and outcomes of care for generalists and specialists.OBJECTIVE: To critically evaluate the differences between generalist physicians and specialists in terms of knowledge, patterns of care, and clinical outcomes of care. METHODS: English-language articles (January 1981 to January 1998) were identified through a Medline search and examination of bibliographies of identified articles. Systematic evaluation of articles relevant to adult medicine that had a direct comparison between generalist physicians and specialists in terms of knowledge relative to widely accepted standards of care, patterns of care (including use of medications, ancillary services, procedures, and resource utilization), and outcomes of care was performed. MAIN RESULTS: In many survey studies, specialists were reported to be more knowledgeable about conditions encompassed within their specialty. In terms of overall practice patterns, specialists practicing in their area of expertise were more likely to use medications associated with improved survival and to comply with routine health maintenance screening guidelines; they used more resources including diagnostic tests, procedures, and longer hospital stays. In the limited number of studies examining the care of patients with acute myocardial infarction, acute nonhemorrhagic stroke, and asthma, specialists had superior outcomes compared with generalists. CONCLUSIONS: There is evidence in the literature suggesting differences between specialists and generalists in terms of knowledge, patterns of care, and clinical outcomes of care for a broad range of diseases. In published studies, specialists were generally more knowledgeable about their area of expertise and quicker to adopt new and effective treatments than generalists. More research is needed to examine whether these patterns of care translate into superior outcomes for patients. Further work is also needed to delineate the components of care for which generalists and specialists should be responsible, in order to provide the highest quality of care to patients while most effectively utilizing existing physician manpower.
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Cancer prevention trials and primary care physicians: factors associated with recommending trial enrollmentBACKGROUND: To explore the willingness of primary care providers (PCPs) to encourage enrollment of patients into cancer prevention trials. METHODS: A self-administered survey was mailed to a random sample of PCPs in three geographic regions. Physicians were asked questions about their knowledge and attitudes towards cancer prevention trials. We presented a clinical vignette of a woman at high risk for breast cancer and asked if they would encourage her enrollment into a breast cancer chemoprevention trial (yes/no). Each survey included one of 16 possible clinical vignettes where patient characteristics (age, race socioeconomic status, physical mobility and co-morbidity) varied dichotomously. Bivariate analyses and logistic models were used to examine the independent effects of patient and physician characteristics on physician decisions. RESULTS: Two hundred and sixty-six surveys (50% response) were analyzed. The mean age of respondents was 48; 54% were White, 35% Asian and 5% Black. By design physicians were evenly distributed by gender, specialty and geographic location. Overall, 53% would encourage enrollment into a breast cancer chemoprevention trial. Significant predictors of a recommendation to enroll were: geographic location in California or Georgia, younger vignette patient and anticipating an increase in patient trust after recommending enrollment. CONCLUSION: PCPs are less likely to encourage elderly patients to enroll into cancer chemoprevention trials. Decisions differ based on geographic location and perceived trust in the patient-provider relationship. To achieve successful enrollment, trial investigators must continue to educate PCPs and ensure a strong PCP-patient relationship is maintained.
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Screening for colorectal cancer on the front lineOBJECTIVE: The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening. METHODS: We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening. RESULTS: Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequently refused, 60% reported sigmoidoscopy was. Frequently cited patient barriers to sigmoidoscopy compliance included fear the procedure would hurt and that patients assume symptoms occur if there is a problem. Perceptions of health systems barriers to sigmoidoscopy were less strong. CONCLUSIONS: Most providers recommended guideline-endorsed colorectal cancer screening. However, patient refusal for sigmoidoscopy was common. Results indicate that multiple levels of intervention, including patient and provider education and systems strategies, may help increase prevalence.