DIFFERENCES IN CLINICAL DECISION-MAKING BETWEEN INTERNISTS AND CARDIOLOGISTS

Background: Whether cardiologists or internists use discretionary test s differently for noncritical cardiological presentations is unclear. Objective: To explore differences in decision making for 3 common scen arios. Methods: We asked 318 cardiologists and 598 internists to manag e scenario patients presenting with (1) uncomplicated syncope, (2) non anginal chest pain, and (3) nonspecific electrocardiographic changes. Participants also estimated baseline clinical risk for each scenario a nd answered questions on uncertainty, malpractice concerns, and cost c onsciousness. We used chi(2) analysis, analysis of variance, and t tes ts to compare management choice and test ordering. Response rate was 5 0%. Results: Initial management choices (ie, admit or discharge, allow or delay surgery) were similar but subsequent testing differed substa ntially. For a 50-year-old woman with uncomplicated syncope, cardiolog ists more often recommended cardiological tests such as exercise tread mill tests (37% vs 18%, 95% confidence interval [CI] for difference: 1 0%-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 proportion s of cardiologists and internists ordered exercise tests (56%) but car diologists recommended thallium studies more often (73% vs 47%, 95% CI for difference: 10%-36%). For all scenarios, average charges for diag nostic evaluations by cardiologists and internists were similar, Concl usions: 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 broa der diagnostic evaluation while cardiologists tended to focus on cardi ological tests. The potential effect on clinical outcomes is unknown.