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Change in Self-Definition from Specialist to Generalist in a National Sample of Physicians

Nicholas A. Christakis, MD, MPH; Jerry A. Jacobs, PhD; and Carla M. Messikomer, PhD
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From the University of Pennsylvania, Philadelphia, Pennsylvania. Requests for Reprints: Nicholas A. Christakis, MD, 338 Fitzwater Street, Philadelphia, PA 19147. Acknowledgments: The authors thank Samuel Preston, PhD, for assistance with the demographic aspects of this paper and Paul Allison, PhD, David Asch, MD, Chris Feudtner, MD, PhD, Renee C. Fox, PhD, Sandy Schwartz, MD, and Sankey Williams, MD, for their helpful suggestions. Grant Support: In part by an NRSA Fellowship from the Agency for Health Care Policy and Research, a Warren-Whitman-Richardson Fellowship from Harvard Medical School, a Peter W. Swazey Fellowship from The Acadia Institute, and a grant from the Boettner Institute of Financial Gerontology (NAC), and a grant from the Leonard Davis Institute of Health Economics and the University of Pennsylvania Institute on Aging, and fellowship support from the Russell Sage Foundation (JAJ).

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;121(9):669-675. doi:10.7326/0003-4819-121-9-199411010-00008
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Objective: Current proposals to reform the health care system call for a physician work force composed of at least 50% generalists. Achieving this objective will likely require that some physicians who are currently specialists become generalists. We sought to determine the extent of such change before any concerted reform efforts and the types of physicians most amenable to such change.

Design: Retrospective cohort study.

Participants: 335 438 physicians in active practice.

Measurements: Rates of change between 1982 and 1986 in self-defined specialties, analyzed with demographic methods and logistic regression.

Results: In 1982, our participants comprised 134 647 (40.1%) generalists and 200 791 (59.9%) specialists. Over the 4-year period of the study, 8319 (6.2%) of the generalists became specialists and 4322 (2.2%) of the specialists became generalists. Although physicians younger than 40 years of age were more likely than those older than 40 years of age to switch into generalist disciplines, specialist physicians between the ages of 40 and 69 years (who accounted for 62.0% of the physician work force) made most of the moves into generalist fields (58.4%). After adjustment for other factors, the physicians most likely to switch into generalist disciplines were women, subspecialty internists, emergency medicine physicians, subspecialty pediatricians, and pathologists. In 1986, the 130 650 physicians (38.9%) in this cohort who considered themselves generalists were supplemented by another 49 226 (14.7%) who considered themselves to have a secondary interest in generalist practice. Physicians with such a secondary interest in 1982 constituted 65% of the new generalists in 1986.

Conclusions: Our findings support three principal conclusions. First, change from specialist to generalist disciplines is not uncommon, even for physicians older than 40 years of age. Second, many physicians already consider a generalist discipline to be a secondary emphasis of their practices. And third, efforts to retrain specialists to be generalists might effectively target those physicians predisposed to become generalists.


Grahic Jump Location
Figure 1.
Overview of movement between specialist and generalist disciplines between 1982 and 1986 for a cohort of 335 438 physicians.
Grahic Jump Location
Grahic Jump Location
Figure 2.
Percentage of physicians entering and leaving generalist disciplines by age.black circles

The graph illustrates the percentage of 200 791 specialists entering (□) and the percentage of 134 647 generalists leaving ( ) generalist disciplines, by age, over a 4-year period from 1982 to 1986. Age is as of 1984.

Grahic Jump Location




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