Institutional change: embracing the initiative to train more generalists.

Dartmouth Medical School was one of 16 U.S. medical schools that received a Generalist Physician Initiative (GPI) grant from The Robert Wood Johnson Foundation in 1994. This article describes institutional change at the school, noting that while the context in which the GPI was launched was receptive, the grant enabled Dartmouth to accelerate institutional changes already under way. Perhaps even more important is that Dartmouth used an approach to change that worked, and although the specific actions may not generalize to other schools, the authors hope the principles will. Key among these principles were capitalizing on a sense of urgency for change, creating and empowering a guiding coalition, developing and communicating the vision, generating short-term wins, consolidating gains, and anchoring new approaches to the existing institutional culture. Changes at Dartmouth are described in the areas of admission and recruitment, undergraduate and graduate medical education, and supporting community practice. The authors also describe shortcomings in developing the program, such as maintaining the guiding coalition in the face of the changing health care system and clinical pressures, developing a vision and strategy in areas managed by the state, and engagement of a broad-based group.