Teaching in Paediatrics for UK Foundation Doctors: A Cross-Sectional Study

Background Most doctors will care for children regularly during their careers in settings such as the emergency department, general practice, surgery, or, for a minority, during paediatric specialist training. As such, exposure to topics related to child health ought to be part of the broad curriculum of learning offered to UK Foundation Programme doctors. Objective This study aimed to quantify teaching in paediatrics that is accessed by Foundation doctors. Methods A cross-sectional electronic survey of foundation year one or two (F1/F2) doctors at the end of the 2020-2021 academic year. Ethical approval was granted by the Imperial College London (ICL) Education Ethics Review Process (EERP 2021-082). Results Two-hundred and five Foundation doctors completed the survey, from 16 of the 18 Foundation schools. Respondents attended a median of two hours (interquartile range (IQR) 0-10) of paediatric teaching during the past 12 months, including a median of one hour (IQR 0-2) of core teaching and a median of one hour (IQR 0-9) of non-core teaching. Those who had worked in a paediatric post in the past 12 months, or who were interested in Paediatrics as a career, attended more median hours of teaching. Conclusions Although many doctors will care for children routinely during their later careers, the number of teaching hours in paediatrics experienced by Foundation doctors is low. The UK Foundation Programme should incorporate more teaching in paediatrics to increase exposure to child health amongst newly graduated and as-yet unspecialised doctors.

Variation in within-host replication kinetics among virus genotypes provides evidence of specialist and generalist infection strategies across three salmonid host species

Theory of the evolution of pathogen specialization suggests that a specialist pathogen gains high fitness in one host, but this comes with fitness loss in other hosts. By contrast, a generalist pathogen does not achieve high fitness in any host, but gains ecological fitness by exploiting different hosts, and has higher fitness than specialists in nonspecialized hosts. As a result, specialist pathogens are predicted to have greater variation in fitness across hosts, and generalists would have lower fitness variation across hosts. We test these hypotheses by measuring pathogen replicative fitness as within-host viral loads from the onset of infection to the beginning of virus clearance, using the rhabdovirus infectious hematopoietic necrosis virus (IHNV) in salmonid fish. Based on field prevalence and virulence studies, the IHNV subgroups UP, MD, and L are specialists, causing infection and mortality in sockeye salmon, steelhead, and Chinook salmon juveniles, respectively. The UC subgroup evolved naturally from a UP ancestor and is a generalist infecting all three host species but without causing severe disease. We show that the specialist subgroups had the highest peak and mean viral loads in the hosts in which they are specialized, and they had low viral loads in nonspecialized hosts, resulting in large variation in viral load across hosts. Viral kinetics show that the mechanisms of specialization involve the ability to both maximize early virus replication and avoid clearance at later times, with different mechanisms of specialization evident in different host-virus combinations. Additional nuances in the data included different fitness levels for nonspecialist interactions, reflecting different trade-offs for specialist viruses in other hosts. The generalist UC subgroup reached intermediate viral loads in all hosts and showed the smallest variation in fitness across hosts. The evolution of the UC generalist from an ancestral UP sockeye specialist was associated with fitness increases in steelhead and Chinook salmon, but only slight decreases in fitness in sockeye salmon, consistent with low- or no-cost generalism. Our results support major elements of the specialist-generalist theory, providing evidence of a specialist-generalist continuum in a vertebrate pathogen. These results also quantify within-host replicative fitness trade-offs resulting from the natural evolution of specialist and generalist virus lineages in multi-host ecosystems.

Generalism in Nature…The Great Misnomer: Aphids and Wasp Parasitoids as Examples

In the present article we discuss why, in our view, the term ‘generalism’ to define the dietary breadth of a species is a misnomer and should be revised by entomologists/ecologists with the more exact title relating to the animal in question’s level of phagy—mono-, oligo, or polyphagy. We discard generalism as a concept because of the indisputable fact that all living organisms fill a unique ecological niche, and that entry and exit from such niches are the acknowledged routes and mechanisms driving ecological divergence and ultimately speciation. The term specialist is probably still useful and we support its continuing usage simply because all species and lower levels of evolutionary diverge are indeed specialists to a large degree. Using aphids and parasitoid wasps as examples, we provide evidence from the literature that even some apparently highly polyphagous agricultural aphid pest species and their wasp parasitoids are probably not as polyphagous as formerly assumed. We suggest that the shifting of plant hosts by herbivorous insects like aphids, whilst having positive benefits in reducing competition, and reducing antagonists by moving the target organism into ‘enemy free space’, produces trade-offs in survival, involving relaxed selection in the case of the manicured agro-ecosystem.

Characterizing the phylogenetic specialism-generalism spectrum of mammal parasites

The distribution of parasites across mammalian hosts is complex and represents a differential ability or opportunity to infect different host species. Here, we take a macroecological approach to investigate factors influencing why some parasites show a tendency to infect species widely distributed in the host phylogeny (phylogenetic generalism) while others infect only closely related hosts. Using a database on over 1400 parasite species that have been documented to infect up to 69 terrestrial mammal host species, we characterize the phylogenetic generalism of parasites using standard effect sizes for three metrics: mean pairwise phylogenetic distance (PD), maximum PD and phylogenetic aggregation. We identify a trend towards phylogenetic specialism, though statistically host relatedness is most often equivalent to that expected from a random sample of host species. Bacteria and arthropod parasites are typically the most generalist, viruses and helminths exhibit intermediate generalism, and protozoa are on average the most specialist. While viruses and helminths have similar mean pairwise PD on average, the viruses exhibit higher variation as a group. Close-contact transmission is the transmission mode most associated with specialism. Most parasites exhibiting phylogenetic aggregation (associating with discrete groups of species dispersed across the host phylogeny) are helminths and viruses.

Host allometry influences the evolution of parasite host-generalism: theory and meta-analysis

Parasites vary widely in the diversity of hosts they infect: some parasite species are specialists—infecting just a single host species, while others are generalists, capable of infecting many. Understanding the factors that drive parasite host-generalism is of basic biological interest, but also directly relevant to predicting disease emergence in new host species, identifying parasites that are likely to have unidentified additional hosts, and assessing transmission risk. Here, we use mathematical models to investigate how variation in host body size and environmental temperature affect the evolution of parasite host-generalism. We predict that parasites are more likely to evolve a generalist strategy when hosts are large-bodied, when variation in host body size is large, and in cooler environments. We then explore these predictions using a newly updated database of over 20 000 fish–macroparasite associations. Within the database we see some evidence supporting these predictions, but also highlight mismatches between theory and data. By combining these two approaches, we establish a theoretical basis for interpreting empirical data on parasites' host specificity and identify key areas for future work that will help untangle the drivers of parasite host-generalism.

This article is part of the themed issue ‘Opening the black box: re-examining the ecology and evolution of parasite transmission’.

Aphid specialism as an example of ecological-evolutionary divergence

Debate still continues around the definition of generalism and specialism in nature. To some, generalism is equated solely with polyphagy, but this cannot be readily divorced from other essential biological factors, such as morphology, behaviour, genetics, biochemistry, chemistry and ecology, including chemical ecology. Viewed in this light, and accepting that when living organisms evolve to fill new ecological-evolutionary niches, this is the primal act of specialisation, then perhaps all living organisms are specialist in the broadest sense. To illustrate the levels of specialisation that may be found in a group of animals, we here provide an overview of those displayed by a subfamily of hemipteran insects, the Aphididae, which comprises some 1600 species/subspecies in Europe alone and whose members are specialised in a variety of lifestyle traits. These include life cycle, host adaptation, dispersal and migration, associations with bacterial symbionts (in turn related to host adaptation and resistance to hymenopterous wasp parasitoids), mutualisms with ants, and resistance to insecticides. As with polyphagy, these traits cannot easily be separated from one another, but rather, are interconnected, often highly so, which makes the Aphididae a fascinating animal group to study, providing an informative, perhaps unique, model to illustrate the complexities of defining generalism versus specialism.

Exposing the structure of an Arctic food web

How food webs are structured has major implications for their stability and dynamics. While poorly studied to date, arctic food webs are commonly assumed to be simple in structure, with few links per species. If this is the case, then different parts of the web may be weakly connected to each other, with populations and species united by only a low number of links. We provide the first highly resolved description of trophic link structure for a large part of a high-arctic food web. For this purpose, we apply a combination of recent techniques to describing the links between three predator guilds (insectivorous birds, spiders, and lepidopteran parasitoids) and their two dominant prey orders (Diptera and Lepidoptera). The resultant web shows a dense link structure and no compartmentalization or modularity across the three predator guilds. Thus, both individual predators and predator guilds tap heavily into the prey community of each other, offering versatile scope for indirect interactions across different parts of the web. The current description of a first but single arctic web may serve as a benchmark toward which to gauge future webs resolved by similar techniques. Targeting an unusual breadth of predator guilds, and relying on techniques with a high resolution, it suggests that species in this web are closely connected. Thus, our findings call for similar explorations of link structure across multiple guilds in both arctic and other webs. From an applied perspective, our description of an arctic web suggests new avenues for understanding how arctic food webs are built and function and of how they respond to current climate change. It suggests that to comprehend the community-level consequences of rapid arctic warming, we should turn from analyses of populations, population pairs, and isolated predator-prey interactions to considering the full set of interacting species.

Do-or-die life cycles and diverse post-infection resistance mechanisms limit the evolution of parasite host ranges

In light of the dynamic nature of parasite host ranges and documented potential for rapid host shifts, the observed high host specificity of most parasites remains an ecological paradox. Different variants of host-use trade-offs have become a mainstay of theoretical explanations of the prevalence of host specialism, but empirical evidence for such trade-offs is rare. We propose an alternative theory based on basic features of the parasite life cycle: host selection and subsequent intrahost replication. We introduce a new concept of effective burst size that accounts for the fact that successful host selection does not guarantee intrahost replication. Our theory makes a general prediction that a parasite will expand its host range if its effective burst size is positive. An in silico model of bacteria-phage coevolution verifies our predictions and demonstrates that the tendency for relatively narrow host ranges in parasites can be explained even in the absence of trade-offs.

Failing to professionalise, struggling to specialise: the rise and fall of health promotion as a putative specialism in England, 1980-2000

Significant attention has been paid to the history of public health in England during the final part of the twentieth century. Within this, however, the field that came to be known as specialist health promotion (SHP) has been relatively neglected. Between 1980 and 2000 those working in this field, generally known as health promotion specialists (HPSs), enjoyed a relative rise in policy and practice prominence before SHP was effectively abandoned by government and others charged with developing and sustaining public-health structures. This paper seeks to explain why the fall of SHP is important; to move towards explaining its rise and decline; and to argue for greater historical attention to be paid to an important but neglected field within health and health care. Essentially, SHP emerged from a set of loose and contingent practices known as health education. A range of important social, economic, organisational and political influences contributed to the slow construction of a putative specialism in health promotion, accompanied by the desire on the part of some (but not all) HPSs to ‘professionalise’ their role. Finally the projects of both specialisation and professionalisation failed, again as a result of then prevailing organisational and political influences. The importance of such a failure in a so-called era of public health is discussed. In the light of this, the paper concludes by briefly setting out an agenda for further research related to the history of SHP.

Ambulatory care provided by office-based specialists in the United States

PURPOSE

Increasing use of specialist services in the United States is leading to a perception of a specialist shortage. Little is known, however, about the nature of care provided by this secondary level of services. The aim of this study was to examine the content of care provided by specialists in community settings, including visits for which the patient had been referred by another physician.

METHODS

Nationally representative visit data were obtained from the National Ambulatory Medical Care Survey (NAMCS) for the years 2002 through 2004. To describe the nature of care, we developed a taxonomy of office-based visit types and constructed logistic regression models allowing for adjusted comparisons of specialty types.

RESULTS

Overall, 46.3% of visits were for routine follow-up and preventive care of patients already known to the specialist. Referrals accounted for only 30.4% of all visits. Specialists were more likely to report sharing care with other physicians for referred, compared with not referred, patients (odds ratio [OR] = 2.99; 95% confidence interval [CI], 2.52-3.55). Overall, 73.6% of all visits resulted in a return appointment with the same physician, in more than one-half of all cases as a result of a routine or preventive care visit.

CONCLUSIONS

Ambulatory office-based activity of specialists includes a large share of routine and preventive care for patients already known, not referred, to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.

Impact of specialist care on clinical outcomes for medical emergencies

General hospitals have commonly involved a wide range of medical specialists in the care of unselected medical emergency admissions. In 1999, the Royal Liverpool University Hospital, a 915-bed hospital with a busy emergency service, changed its system of care for medical emergencies to allow early placement of admitted patients under the care of the most appropriate specialist team, with interim care provided by specialist acute physicians on an acute medicine unit - a system we have termed 'specialty triage'. Here we describe a retrospective study in which all 133,509 emergency medical admissions from February 1995 to January 2003 were analysed by time-series analysis with correction for the underlying downward trend from 1995 to 2003. This showed that the implementation of specialty triage in May 1999 was associated with a subsequent additional reduction in the mortality of the under-65 age group by 0.64% (95% CI 0.11 to 1.17%; P=0.021) from the 2.4% mortality rate prior to specialty triage, equivalent to approximately 51 fewer deaths per year. No significant effect was seen for those over 65 or all age groups together when corrected for the underlying trend. Length of stay and readmission rates showed a consistent downward trend that was not significantly affected by specialty triage. The data suggest that appropriate specialist management improves outcomes for medical emergencies, particularly amongst younger patients.

Health care becomes an industry

The delivery of health care is in the process of "industrialization" in that it is undergoing changes in the organization of work which mirror those that began in other industries a century ago. This process is characterized by an increasing division of labor, standardization of roles and tasks, the rise of a managerial superstructure, and the degradation (or de-skilling) of work. The consolidation of the health care industry, the fragmentation of physician roles, and the increasing numbers of nonphysician clinicians will likely accelerate this process. Although these changes hold the promise of more efficient and effective health care, physicians should be concerned about the resultant loss of autonomy, disruption of continuity of care, and the potential erosion of professional values.

American internal medicine in the 21st century: can an Oslerian generalism survive?

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.

Physician specialization and antiretroviral therapy for HIV

BACKGROUND

Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has important implications for the types of physicians that can best care for patients with HIV infection.

OBJECTIVE

To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART).

DESIGN

Observational cohort study of patients under care for HIV infection and their physicians.

PATIENTS AND SETTING

This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians.

MEASUREMENTS

Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor.

RESULTS

Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio [OR], 0.32; 95% confidence interval [95% CI], 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations.

CONCLUSIONS

Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that expert generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists.

Specialty training and specialization among physicians who treat HIV/AIDS in the United States

OBJECTIVE

To assess the association of specialty training and experience in the care of HIV disease with HIV-specific knowledge, referral patterns, and HIV-related education activities.

DESIGN

Cross-sectional survey.

SETTING

The United States.

PARTICIPANTS

Physicians caring for patients in the HIV Costs and Service Utilization Study, a study of a probability sample of HIV-infected individuals in the United States.

MEASUREMENTS AND MAIN RESULTS

Measures included physicians' reports of specialty training and HIV caseload, scores on an HIV-specific knowledge test, referral patterns, and attendance rates at HIV-related educational activities. Approximately 72% (379) of the eligible physicians completed a survey. Of these, 152 (40%) had infectious disease (ID) training, and 213 (56%) were generalists; 4% of ID-trained physicians and 37% of generalist physicians did not consider themselves HIV experts. The median current caseloads were 150 and 200 patients for ID experts and generalist experts, respectively. In contrast, the median caseload for non-expert generalists was 5. Mean scores on the knowledge scale were similar for ID and generalist experts (9.0 items correct out of 11 vs 8.5; P=not significant), but lower for generalist non-experts (6.5 items correct; P <.01). Experts had attended more local and national HIV meetings than non-experts (9.3 vs 2.7; P <.01, and 2.3 vs.40; P <.01, respectively) in the past year. Fewer ID experts ever referred than generalist experts (13.0% vs 27.3%; P=.01). In multivariable models that included specialty training and caseload, physicians with caseloads of 20 to 49 and >50 were more likely to have a high knowledge score (defined as 80% or more correct, odds ratio [OR], 2.8; P=.04 and OR, 5.7; P <.001, respectively), and the effect of specialty was attenuated (OR, 2.7; P=.02 decreased from OR, 7.8; P <.001 in a model without caseload). In the models predicting referral practices, both experience (OR,.25; P <.01 and OR,.17; P <.01 for caseloads of 20 to 49 and >50, respectively) and specialty (OR,.19; P <.01 and OR,.09; P <.01 for generalist and ID experts, respectively) were significant.

CONCLUSIONS

In a national sample of physicians, HIV-specific knowledge was more strongly associated with HIV caseload than with specialty training. In addition, although referral practices were related to both experience and specialty, generalist experts and ID physicians reported similar behaviors. This suggests that generalist physicians, through clinical experience and self-education, can develop specialized knowledge in HIV care.

Residency application statements can predict postresidency training

We sought to evaluate whether residency application statements regarding expected career paths are accurate predictors of early postresidency career paths. We evaluated 162 residents who completed a categorical medicine residency at Georgetown University Hospital between 1990 and 1998 to determine if their stated career plans (generalist practice, subspecialization, or undecided) at application predicted activity immediately after residency. Of 130 residents with defined postresidency plans at application, most 78 (60%) followed those career paths after graduation; 18 (67%) of 27 pursued their initial interest in generalist practice, and 60 (58%) of 103 pursued their stated interest in subspecialty training. We also noted a movement of residents toward generalism (79 [49%] of 162), despite low initial interest (27 [17%] of 162).