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March 10, 1997

Differences in Clinical Decision Making Between Internists and Cardiologists

Author Affiliations

From the Department of Medicine, Veterans Affairs Medical Center, Los Angeles, Calif (Dr Glassman); RAND, Santa Monica, Calif (Drs Glassman and Kravitz); UCLA School of Medicine (Dr Glassman) and Department of Health Services, School of Public Health (Ms Petersen), University of California, Los Angeles; Department of Medicine and the Center for Health Services Research in Primary Care, University of California, Davis (Dr Kravitz); and School of Business Administration, University of Southern California, Los Angeles (Dr Rolph).

Arch Intern Med. 1997;157(5):506-512. doi:10.1001/archinte.1997.00440260044008

Background:  Whether cardiologists or internists use discretionary tests differently for noncritical cardiological presentations is unclear.

Objective:  To explore differences in decision making for 3 common scenarios.

Methods:  We asked 318 cardiologists and 598 internists to manage scenario patients presenting with (1) uncomplicated syncope, (2) nonanginal chest pain, and (3) nonspecific electrocardiographic changes. Participants also estimated baseline clinical risk for each scenario and answered questions on uncertainty, malpractice concerns, and cost consciousness. We used χ2 analysis, analysis of variance, and t tests to compare management choice and test ordering. Response rate was 50%.

Results:  Initial management choices (ie, admit or discharge, allow or delay surgery) were similar but subsequent testing differed substantially. For a 50-year-old woman with uncomplicated syncope, cardiologists more often recommended cardiological tests such as exercise treadmill tests (37% vs 18%, 95% confidence interval [CI] for difference: 10%-28%) and signal-averaged electro-cardiograms (13% vs 4%, 95% CI for difference: 3%-15%) but less often requested neurological tests (29% vs 37%, 95% CI for difference: —17% to 1%). For a 42-year-old man with nonanginal chest pain, cardiologists more frequently ordered exercise tests (70% vs 51%, 95% CI for difference: 10%-28%). For a 53-year-old woman with nonspecific electrocardiographic changes, equal proportions of cardiologists and internists ordered exercise tests (56%) but cardiologists recommended thallium studies more often (73% vs 47%, 95% CI for difference: 10%-36%). For all scenarios, average charges for diagnostic evaluations by cardiologists and internists were similar.

Conclusions:  In 3 noncritical cardiology scenarios, discretionary test use by cardiologists and internists differed substantially, although this was not reflected in dollar resources. Internists tended toward a broader diagnostic evaluation while cardiologists tended to focus on cardiological tests. The potential effect on clinical outcomes is unknown.Arch Intern Med. 1997;157:506-512