Donohoe M T
Division of General Internal Medicine, Oregon Health Sciences University, Portland 97201, USA.
Arch Intern Med. 1998;158(15):1596-608. doi: 10.1001/archinte.158.15.1596.
Policymakers, managed care organizations, medical educators, and the general public are showing an increasing interest in the amount and quality of care provided by generalists and subspecialists. This article reviews studies comparing the knowledge base of and quality of care provided by these 2 groups of physicians. English-language articles were identified through MEDLINE (1966-present) using the following keywords: generalist, generalism, (sub)specialist, (sub)specialty, (sub)specialization, consultation, referral, and quality of care, and through the bibliographies of these citations. All studies were evaluated. With respect to quality of care, only American studies were chosen. Data quality was assessed by me. Evidence is strongest that the knowledge base and quality of care provided by specialists exceeds those of generalists for certain conditions such as myocardial infarction, depression, and acquired immunodeficiency syndrome. Differences in many other areas are multifactorial, and often a function of study design or patient selection. The differences, however, are not as striking or important to the health of the public at large as those deficiencies in disease management, preventive care, and health maintenance that are common to all physicians. Furthermore, overuse of diagnostic and therapeutic modalities by certain specialists leads to increased costs with either no benefit or added risks to patients. The quality and coordination of care provided by generalists and specialists may be improved through changes in education and training, via quality improvement methods of providing patient care, and by increasing visit length and optimizing use of referrals and strategies for generalist-specialist comanagement. Further study of these areas is warranted and should concentrate on outcomes.
政策制定者、管理式医疗组织、医学教育工作者以及普通公众，对全科医生和专科医生所提供医疗服务的数量和质量表现出越来越浓厚的兴趣。本文回顾了比较这两组医生的知识基础和所提供医疗服务质量的研究。通过MEDLINE（1966年至今），使用以下关键词检索英文文章：全科医生、全科医学、（亚）专科医生、（亚）专科、（亚）专业化、会诊、转诊和医疗服务质量，并通过这些引用文献的参考文献进行检索。对所有研究进行了评估。在医疗服务质量方面，仅选择了美国的研究。由我对数据质量进行评估。有最充分的证据表明，在某些病症如心肌梗死、抑郁症和获得性免疫缺陷综合征方面，专科医生的知识基础和所提供的医疗服务质量超过全科医生。许多其他领域的差异是多因素的，而且往往是研究设计或患者选择的结果。然而，这些差异对于广大公众健康的影响，并不像所有医生在疾病管理、预防保健和健康维护方面的普遍不足那样显著或重要。此外，某些专科医生过度使用诊断和治疗手段会导致成本增加，而对患者没有益处或只会增加风险。通过改变教育和培训方式、采用提高医疗服务质量的方法、增加就诊时间以及优化转诊使用和全科医生与专科医生共同管理的策略，可以改善全科医生和专科医生所提供医疗服务的质量和协调性。有必要对这些领域进行进一步研究，且应集中关注结果。
