Differences in clinical decision making between internists and cardiologists.
BACKGROUND
Whether cardiologists or internists use discretionary tests differently for noncritical cardiological presentation 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 chi 2 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 electrocardiograms (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.
Glassman
P A
PA
Department of Medicine, Veterans Affairs Medical Center, Los Angeles, Calif, USA.
Kravitz
R L
RL
Petersen
L P
LP
Rolph
J E
JE
D002309:Cardiology; D002637:Chest Pain / Q000175:diagnosis; D015510:Clinical Medicine; D003657:Decision Making; D003937:Diagnosis, Differential; D004562:Electrocardiography; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis / Q000503:physiopathology; D006760:Hospitalization; D006801:Humans; D007388:Internal Medicine; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D012306:Risk; D013575:Syncope / Q000175:diagnosis