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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.
There is not a consensus in the medical community about what types of physicians are best suited to taking care of HIV-infected patients.1–3 As HIV treatment becomes more complex, physicians with specialty training in infectious diseases (IDs) are often delivering care. While some advocate for care by specialists,2 many believe that AIDS care should continue to be based in primary care settings because AIDS care often requires teams of providers with different skills.1,3,4 Optimizing quality of care requires specialty care as well as core features of primary care such as accessibility, coordination, comprehensiveness, and continuity.1
Consequently, what constitutes expertise in the context of HIV care is a complex issue that may not conform to traditional distinctions between specialists and generalists. We theorized that expertise in the treatment of a particular condition would be related to both specialty training and specialization. By specialty training we mean residency, fellowship, or other formal training and/or board certification in a particular area. By specialization we mean experience and focus in a particular clinical area. A physician without formal training in a particular area might take a particular interest in a condition by following the current literature, attending conferences, seeking out patients with the condition for care, and/or participating in clinical research. For instance, a general internist might choose to focus on women's health or a cardiologist might choose to focus on congestive heart failure. Thus, we use the term “specialization” here to refer to the experience, skills, and knowledge necessary to competently care for patients with specific conditions, irrespective of formal training.
No study that we are aware of has examined the relationship between formal specialty training and informal specialization for providers of HIV care or for other chronic conditions. To better understand this issue, we surveyed physicians caring for a national probability sample of patients with HIV infection. We first examined the relationship between specialty training in infectious diseases and HIV specialization, using current HIV caseload and self-assessed expertise as indicators of specialization. Next, we examined the relationship of specialty training and HIV specialization to HIV-care knowledge levels, referral rates, and rates of attendance at HIV-related continuing medical education (CME) activities. We hypothesized that generalist physicians who identified themselves as HIV experts would have knowledge levels, referral rates, and attendance at HIV-related CME activities that were similar to infectious disease specialists.
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Of the 551 clinicians with correct addresses, 412 (75%) responded to the survey (60% of all physicians identified). Thirty-three of these were nurse practitioners or physician's assistants whom HCSUS participants had identified as physicians; we eliminated these. This left a total of 379 responses (Fig. 1). In general, there was no difference in response rates by region of the country, but respondents tended to have more patients enrolled in HCSUS (mean number identified, 4.8 vs 2.3; P < .01). We had no other information with which to compare responders to nonresponders. Item completion rates ranged from 88% (income) to 100%, with most items completed by 99% or more of the respondents.
The average age of the respondents was 44 years, and 73% were male, although male physicians treated 83% of patients (Table 1). Fifty-six percent of the physicians identified themselves as general physicians. Physicians with ID training, however, cared for 46% of the patients. Seventy-eight percent classified themselves as white while 7% were African American. Approximately a third of the sample had an annual income of less than $100,000/year. The physicians spent approximately 33 hours per week in patient care and derived approximately 72% of their income from patient related activities. The average physician saw approximately 60 patients/week. Twenty percent of the physicians identified their sexual orientation as mostly or exclusively homosexual.
Table 1. Physician Demographics and Training*
| ||Physician Characteristics (N = 379)||Physician Characteristics Weighted to Reflect Patients Under Care Nationally†|
| Age, y (±SD)||43.9 (7.7)||45.8 (6.5)|
| Number of years since graduation from medical school, y (±SD)||16.5(7.8)||19.0(6.7)|
| Sexual preference (mostly or exclusively homosexual)||20.0||20.0|
|Primary fields of medicine|
| General medicine||56||51|
| Infectious diseases||40||47|
| Other (largely medical subspecialties)||4||3|
| African American||7||5|
|Annual income (n = 370)|
| Less than $100,000||33||21|
| More than $150,000||23||37|
|Physicians receiving more than half their pay in salary (n = 306)||85||85|
|Patient care activities (±SD)|
| Half days per week in patient care, n||6.3 (3.1)||6.4 (2.8)|
| Outpatients per week, n||60.6 (45.0)||78.9 (42.3)|
| Hours in direct patient care per week, n||32.8 (18.1)||37.2 (18.4)|
| Mean percent of income from patient care||71.9 (34.1)||79.2 (29)|
HIV-Specific Experience and Training
Table 2 presents data on HIV-specific experience and practice characteristics by specialty training (classified as general medicine/other or ID) and then, within specialty, by whether the physician was a self-rated expert in HIV care. Physicians trained in infectious diseases were more likely to consider themselves expert in HIV care than physicians in the general medicine or other category (96% vs 63%; P < .01). For most of the characteristics in Table 2, infectious disease physicians and self-rated experts within general medicine were similar. Median current caseloads were greater for general medicine experts than for ID experts (200 vs 150 patients; P < .05). In contrast, the average caseload for other general medicine physicians was 5. Three percent of ID and 4% of general medicine experts had fewer than 20 active cases compared with 74% of general medicine physicians who did not consider themselves HIV experts (P < .01). These low-volume physicians cared for an estimated 13,115 HIV-infected patients across the country, or about 8.5% of patients in care for HIV. General medicine physicians spent more time in outpatient practice and saw more patients per week than did ID physicians, although the amount of time spent in clinical practice was similar for both specialties. For 21% of nonexpert general physicians, the majority of their patients had injection drug use as a risk factor for acquiring HIV, as compared to just 14% of general medicine specialists and 16% of ID specialists (P = not significant [NS]).
Table 2. Practice Characteristics and Behaviors of Physicians by Training and Self-assessed HIV Expertise
| ||Self-rated “Expert in HIV”|
|Infectious Diseases–trained||General Medicine and Others|
|No (n = 6)||Yes (n = 146)*||No (n = 83)||Yes (n = 144)†,‡|
| Current case load, median (±SD)||22.5 (98)||150 (209)‖||5 (73)||200 (259)¶,+|
| With fewer than 20 current cases, n (%)||2 (33.3)||5 (3.4)¶||61 (73.5)||6 (4.2)¶|
| Cumulative case load, median (±SD)||100 (237)||400 (1,300)¶||20 (256)||500 (1,423)¶|
|HIV patient population risk factors, %|
| Majority of cases with IV drug use as a risk factor||0||16.4||20.5||13.9|
| Majority of cases with homosexual contact as a risk factor||83.3||65.8||55.4||72.2‖|
| Majority of cases with heterosexual contact as a risk factor||16.7||11.6||21.7||11.8‖|
|Practice characteristics, mean (±SD)§|
| Half days per week in patient care||2.0 (2.0)||4.9 (3.0)‖||7.0 (3.0)||7.5 (2.7)++|
| Outpatients per week||15.5 (18.0)||40.0 (33.5)‖||79.9 (54.3)||72.2 (40.4)++|
| Hours in direct patient care per week||12.5 (15.1)||30.7 (20.8)‖||35.5 (18.2)||34.2 (14.4)|
On average, physicians were correct on 8.2 (75%) of the 11 questions in the HIV knowledge scale and about one half were correct on more than 80% (Table 3). Infectious disease physicians had an average of 1 more correct question than generalist physicians and 69% had more than 80% correct, as compared to only 45% of general physicians (P < .01). Self-rated experts had higher average scores than did those who did not consider themselves experts (8.7 vs 6.6; P < .01), and self-rated experts within general medicine had scores that were similar to scores for ID specialists (8.5 vs 9.0; P = NS). Physicians with higher current patient volumes (>50 patients) scored higher than did those with fewer than 20 patients (8.8 vs 6.4; P < .01). For physicians with fewer than 20 patients, there was a positive association between caseload and score (e.g., an average score of 6.0 for physicians with fewer than 10 patients versus a score of 7.2 for those with between 10 and 18 patients; P < .05).
Table 3. Physician Formal Training and Experience and HIV-specific Knowledge
| ||Number of Respondents||Average Number Correct (%)||Proportion >80% Correct|
|All providers||379||8.2 (75)||0.54|
| Infectious diseases||152||8.9 (81)||0.69|
| General medicine||213||7.9 (71)||0.45|
| Other||14||6.7 (61)||0.36|
| No||89||6.6 (60)||0.27|
| Yes||290||8.7 (79)||0.63|
|Formal training and self-rated expertise*|
| Infectious diseases|
| Non “experts”||6||7.8 (71)||0.50|
| “Experts”||146||9.0 (81)||0.70|
| General medicine or other|
| Non “experts”||83||6.5 (59)||0.25|
| “Experts”||144||8.5 (77)||0.56|
|Self-rated HIV knowledge*|
| Extremely knowledgeable||205||8.8 (80)||0.65|
| Very knowledgeable||121||8.3 (76)||0.55|
| Somewhat or not knowledgeable||53||5.9 (53)||0.11|
|Current HIV case load*|
| 0–19||74||6.4 (58)||0.20|
| 20–49||44||8.4 (76)||0.50|
| ≥50||261||8.8 (80)||0.65|
Referral Patterns and Rates of CME Activity
Similar associations were observed for the relationships of experience and training with HIV-related referral patterns, involvement of patients in clinical trials, and attending local and national HIV-related CME activities. Fourteen percent of infectious disease physicians reported that they would ever refer versus 46% of general and other physicians (P < .01; Table 4). General medicine physicians who rated themselves as experts reported that they would refer less often than nonexperts (27% vs 82%; P < .01) and had rates closer to those reported by ID physicians. Compared to ID physicians, general medicine experts were more likely to refer for evaluating possible changes in antiretroviral therapy (22% vs 11%; P = .01) and choosing alternative prophylactic regimens for opportunistic infections (16% vs 8%; P = .02). The referral rates for the individual items were lowest for the initial evaluation of an HIV-infected patient (4% for general medicine experts, 2% for ID physicians, and 44% for general medicine physicians without expertise) and highest for evaluating possible changes in antiretroviral therapy (22% for general medicine experts, 11% for ID physicians, and 78% for general medicine physicians without expertise).
Table 4. Relationships of Specialty Training, Experience, and Self-assessed Specialization to Referral Patterns and Participation in CME Activities/Meetings
| ||Number of Respondents||Ever Refer,*%||Local Meetings Attended*† Mean (±SD)||National Meetings Attended*† Mean (±SD)||Enrollment in Clinical Trials,‡% (±SD)|
|All providers||379||33.5||7.7 (10.7)||1.9 (2.8)||14.2 (16.9)|
|Formal training|| ||§|| ||‖||§|
| Infectious diseases||152||13.8||9.4 (11.7)||2.4 (3.1)||18.2 (18.9)|
| General medicine||213||46.2||6.7 (10.1)||1.6 (2.6)||11.8 (15.2)|
| Other||14||57.1||6.1 (7.6)||0.8 (1.1)||9.2 (9.9)|
|Self-rated experts|| ||§||§||§|| |
| Yes||290||20.1||9.3 (11.5)||2.3 (3.1)||15.0 (15.9)|
| No||89||78.1||2.7 (5.0)||0.4 (0.8)||11.6 (19.7)|
|Formal training and self-rated expertise|| ||§||§||§||§|
| Infectious diseases|
| Non “expert”||6||33.3||4.5 (4.3)||1.8 (1.2)||45.3 (32.6)¶|
| “Expert”||146||13.0||9.6 (11.8)||2.4 (3.2)||17.0 (17.4)|
| General medicine or other|
| Non “expert”||83||81.5||2.6 (5.0)||0.3 (0.6)||9.2 (16.2)|
| “Expert”||144||27.3||9.0 (11.2)||2.2 (3.0)||13.0 (14.1)|
|Self-rated HIV knowledge|| ||§||§||§|| |
| Extremely knowledgeable||205||16.6||10.2 (12.4)||2.6 (3.5)||16.1 (15.9)|
| Very knowledgeable||121||40.8||6.2 (8.2)||1.3 (1.3)||11.8 (14.8)|
| Somewhat or not knowledgeable||53||84.3||1.6 (2.3)||0.3 (0.6)||12.6 (23.5)|
|Current HIV caseload|| ||§||§||§|| |
| 0–19||74||83.1||2.7 (5.4)||0.46 (0.8)||12.0 (20.4)|
| 20–49||44||34.1||7.2 (11.0)||1.39 (1.4)||14.8 (17.8)|
| ≥50||261||19.9||9.3 (11.4)||2.3 (3.2)||14.8 (15.7)|
Self-rated experts in both infectious diseases and general medicine reported that they attended more local (9.6 and 9.0, respectively) and national (2.4 and 2.2, respectively) CME meetings than did nonexpert generalists (2.6 local meetings and 0.3 national meetings; P < .01). In contrast, ID physicians had more patients enrolled in clinical trials (17%) when compared with general medicine experts (13%) and general medicine nonexperts (9%; P < .01).
For physicians who rated themselves as extremely, very, and somewhat or not knowledgeable, rates of ever referring were 17%, 41%, and 84%, respectively (P < .01 for trend). Physicians who rated themselves as extremely knowledgeable attended 10.2 local CME meetings per year, compared with 6.2 and 1.6 meetings per year for those in the next 2 knowledge categories (P < .01).
Twenty percent of physicians with high caseloads (>50 patients) reported that they would ever refer versus 34% of those with 20 to 50 patients and 83% of those with fewer than 20 patients (<.01). Similarly, physicians with high caseloads also attended more local and national CME meetings, although enrollment in clinical trials was similar for both high- and low-volume physicians.
Multivariable Correlates of Knowledge and Referrals
Table 5 shows the relationships of the composite training/experience variable and current caseload to knowledge levels. When current caseload is considered individually (column 2), physicians following 20 to 49 patients (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.8 to 10.1) or 50 or more patients (OR, 8.9; 95% CI, 4.6 to 17.1) were more likely than were those following fewer than 20 patients to score 80% or higher on the knowledge scale. When the composite training/experience variable is considered individually (column 2), generalist HIV experts (OR, 4.3; 95% CI, 2.3 to 7.9) and ID trained physicians (OR, 7.8; 95% CI, 4.1 to 14.7) were both more likely than were nonexpert generalists to score 80% or higher on the knowledge scale. When these 2 variables are examined simultaneously (column 3), a caseload of 50 or more patients is still significantly associated with knowledge (OR, 5.7; 95% CI, 2.4 to 13.6). The association of ID training with knowledge, however, is now markedly attenuated (OR, 2.7; 95% CI, 1.2 to 6.2), suggesting that the effects of specialty training on knowledge may largely be explained by HIV caseload.
Table 5. Multivariable Effects of Specialty Training and Caseload on Knowledge Levels and Referrals, Individually and in Combination*
| ||Knowledge Level||Referrals|
|Effects of Specialty Training and Caseload Looked at Individuality||Effects of Specialty Training and Caseload Looked at in Combination||Effects of Specialty Training, Caseload, and Knowledge Looked at Individually||Effects of Specialty Training, Caseload, and Knowledge Looked at in Combination|
| 0–19 (omitted category)||—||—||—||—|
| 20–49||4.3 (1.8 to 10.1)||2.8 (1.1 to 7.3)||.08 (.03 to 0.21)||.25 (.09 to 0.75)|
| 50+||8.9 (4.6 to 17.1)||5.7 (2.4 to 13.6)||0.04 (0.02 to 0.08)||0.17 (0.07 to 0.45)|
| General medicine nonexpert||—||—||—||—|
| General medicine expert||4.3 (2.3 to 7.9)||1.4 (0.6 to 3.2)||0.06 (0.03 to 0.13)||0.19 (0.08 to 0.49)|
| ID trained||7.8 (4.1 to 14.7)||2.7 (1.2 to 6.2)||0.03 (0.01 to 0.06)||0.09 (0.03 to 0.22)|
|Knowledge level†||—||—||0.20 (0.13 to 0.33)||0.39 (0.22 to 0.69)|
The relationships between current caseload, the composite knowledge/experience, and knowledge levels to referral rates are also shown in Table 5 (columns 4 and 5). In column 4, each of these 3 variables is considered individually. After controlling for race, gender, and patient HIV risk factor profile, physicians with caseloads of 20 to 49 patients (OR, 0.08; 95% CI, 0.03 to 0.21) or 50 or more patients (OR, 0.04; 95% CI, 0.02 to 0.08) were less likely than were physicians with fewer than 20 patients to ever refer. Both generalist HIV experts (OR, 0.06; 95% CI, 0.03 to 0.13) and ID-trained physicians (OR, 0.03; 95% CI, 0.01 to 0.06) were less likely to ever refer than were generalist nonexperts. A higher knowledge score was also associated with referring less often (OR, 0.20; 95% CI, 0.13 to 0.33). When these 3 variables were considered jointly (column 5), we observed similar findings. Caseloads of 20 to 49 patients (OR, 0.25; 95% CI, 0.09 to 0.75) and caseloads of 50 or greater patients (OR, 0.17; 95% CI, 0.07 to 0.45) were associated with lower rates of ever referring. Both generalist experts (OR, 0.19; 95% CI, 0.08 to 0.49) and ID-trained physicians (OR, 0.09; 95% CI, 0.03 to 0.22) referred less often than did generalist nonexperts, and physicians with higher knowledge scores referred less often (OR, 0.39; 95% CI, 0.22 to 0.69).
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The debate about who should care for patients with HIV infection or other chronic diseases often focuses on specialty training. This focus fails to account for disease-specific experience and the knowledge and skills that physicians might acquire through such experience and other clinical or educational activities. Our study is the first that we are aware of to provide national data on the relationships between specialty training and specialization, and how they relate to physician knowledge and selected physician behaviors. We hypothesized that expertise in the treatment of a particular condition would be most related to both specialty training and specialization, but that specialization, as primarily measured by experience, would be the most important factor.
These results confirm our hypotheses in a nationwide representative sample of physicians caring for adults with HIV infection. Among generalist physicians, expertise was strongly associated with caseload, knowledge, referral rates, and rates of participation in CME activities. We found no important difference between physicians trained in infectious diseases and general physicians who consider themselves experts in HIV care on caseload and attendance at local and national meetings. Infectiousdiseases–trained physicians, however, had slightly higher HIV-related knowledge scores and referred less often. In multivariable models that controlled for caseload and self-assessed expertise, caseload was the most important predictor of knowledge scores. This suggests that interest and involvement in HIV care by a physician, as manifested by caseload, keeping up with the literature, and attending meetings, are related to disease-specific expertise, regardless of specialty training.
Other studies have shown that specialists are usually more knowledgeable than generalists about diagnostic techniques13,14 and efficacious therapies.15–20 In addition, when processes of care are examined (using chart reviews or patients' reports), for acute myocardial infarction (MI),15,21 unstable angina,22 asthma,23 acute arthritis,24,25 multiple sclerosis,26 and depression,27 specialists tended to provide care deemed appropriate at higher rates than did generalists. While ID physicians in our study had slightly higher knowledge levels and different behaviors than generalist HIV experts, it appears that physicians not trained in ID can, by virtue of interest, clinical experience, CME activities, and other methods of self-education such as reading medical journals and newsletters, develop similar levels of HIV expertise.
We found that generalists who do not claim to have expertise in HIV refer more than generalists who do have expertise. As expected, physicians with training in infectious diseases had the lowest rate of referral for the 5 clinical scenarios presented. While we cannot examine the appropriateness of these referrals, one might assume that higher rates of referral are an appropriate response for nonexpert physicians and that this does not indicate lower quality or inappropriate care. Several studies of acute MI have shown the value of specialists and generalists working together in consultative relationships,28 and collaborative management has clearly been shown effective in the treatment of depression.29 In addition, constraints imposed by the health care delivery system might also contribute to lower rates of referrals for ID specialists, particularly for patients who require approval of referrals from primary care physicians.
Kitahata et al. found that AIDS patients in the Group Health Cooperative treated by more experienced clinicians (defined as >5 cases) had lower mortality, as compared with patients treated by other clinicians.30 That study, however, was conducted before the advent of newer therapies and in a single organization where most of the physicians were family practitioners with very low patient volumes. Turner et al. demonstrated that patients with HIV infection cared for by generalists were more frequently hospitalized, and Markson et al. showed that generalists were slower to adopt the use of zidovudine.31,32 In addition, Curtis et al. and Paauw et al. suggest that generalist physicians have fewer skills than do specialists in diagnosing HIV-related complications, including recognizing HIV-related skin conditions and diagnosing Pneumocystis carinii pneumonia.33,34 These studies, however, only examined formal training and were not able to account for HIV-specific experience and interests. Similarly, studies in cardiology21,35 and other specialties36 have also focused only on formal training. More recently, in a national survey, Stone et al. demonstrated that both training in infectious diseases and HIV experience were associated with prescribing appropriate antiretroviral regimens. That study, however, included physicians who were not necessarily the principal physicians for patients with HIV infection. Their findings were not significant when the analysis was restricted to physicians who would not refer patients for the management of HIV.37
Our study has several limitations. First, we do not know if the knowledge scale we used predicts care quality, and we do not have external criteria to assess the extent to which absence of knowledge will lead to poor care. However, nationally recognized experts selected questions that they thought reflected knowledge necessary to provide state-of-the-art care. Extensive pretesting that included groups of both HIV specialist physicians and generalist physicians with no particular expertise in the treatment of HIV infection demonstrated that the scale was able to discriminate between these 2 types of physicians. Second, as with all surveys, we rely on self-reports for our measures of specialty training, experience, and expertise. We see no reason, however, why error in reporting would tend to bias the associations we examined. Third, HCSUS did not include patients in prisons or the military and patients not receiving care. This is, however, the only nationally representative population of HIV-infected patients that we are aware of, and these patients identified our physician sample. We believe that our results can be generalized to physicians caring for patients with HIV infection in the United States. One additional caveat, however, is that HIV/AIDS may be atypical when compared to other chronic diseases in that when HIV first emerged, care was not uniformly embraced by ID specialists and was often delivered in community settings by generalists physicians. In the current environment, it might be more difficult for a non–ID-trained physician to develop similar expertise in HIV-related care. This would suggest, however, that in order to establish competency among current internal medicine residents, training programs should involve residents in the outpatient care of HIV-infected patients in settings where they can be supervised by experts in HIV-related care.
In summary, our results suggest that if we are to understand better the factors underlying reported associations between either specialty or volume and quality of care and/or outcomes, we should study both formal training and experience with a particular condition. Our data strongly suggest that general physicians are able to develop condition-specific knowledge similar to that of physicians with specialty training if they have a substantial case load and make an effort to stay current in a particular area. Specifically, we recommend that in future studies of HIV care, physicians be classified according to HIV caseload and whether they consider themselves experts in HIV care, in addition to classification by formal training. If there is concern that the latter type of measure is too subjective, other indicators, such as attendance at HIV clinical meetings, could be used. It remains to be determined whether these findings can be generalized to the care of patients with other chronic conditions. Further studies also are required to assess whether such knowledge translates into appropriate clinical practices and subsequent good outcomes. It will also be important to know if contextual factors, such as practicing with other specialists, modify the relationships described here.