Background The respective roles of generalist and specialistphysicians in the care of patients are currently a matter ofdebate. Information is limited about the knowledge and practicesof generalist and specialist physicians regarding conditionsthat both groups treat, such as myocardial infarction.
Methods We therefore surveyed 1211 cardiologists, internists,and family practitioners in the states of New York and Texasabout four treatments demonstrated by randomized clinical trialsto be associated with improved survival after myocardial infarction(thrombolytic therapy, immediate and long-term use of aspirin,and long-term use of beta-blockers) and two treatments for whichsuch evidence is lacking (diltiazem for patients with pulmonarycongestion and prophylactic lidocaine). We asked physiciansabout the effect of each treatment on survival and the likelihoodthat they would prescribe each class of drugs.
Results For the four beneficial treatments, the cardiologistsbelieved more strongly than the internists and family physiciansthat survival was improved by the treatment, and they were morelikely to prescribe these drugs (P<0.001). For example, 94.1percent of cardiologists said they were very likely to prescribethrombolytic agents to treat an acute myocardial infarction,as compared with 82.0 percent of internists and 77.3 percentof family practitioners. Conversely, for the two treatmentsfor which trials showed no evidence of a survival benefit, cardiologistswere less likely than internists and family practitioners tothink there was such a benefit and less likely to prescribethe drugs (P<0.001). For example, 4.7 percent of cardiologistsreported that they were very likely to use prophylactic lidocaine,as compared with 13.1 percent of internists, and 16.5 percentof family practitioners. When we used logistic regression toadjust for potential confounders, all the differences betweenthe cardiologists and the internists and family practitionersremained significant (P<0.02).
Conclusions Internists and family practitioners are less awareof or less certain about key advances in the treatment of myocardialinfarction than are cardiologists. This finding underscoresthe need to improve the dissemination of information from clinicaltrials to generalist physicians, particularly if they are tohave an enlarged role in the evolving health care system.
Source Information
From the Division of General Medicine, Section on Health Services and Policy Research (J.Z.A.), and the Cardiovascular Division (P.J.H., E.M.A.) of the Department of Medicine, and the Department of Radiology (B.J.M.), Brigham and Women's Hospital and Harvard Medical School, Boston, and the Department of Health Care Policy, Harvard Medical School, Boston (J.Z.A., E.G., C.L.P., B.J.M.).
Address reprint requests to Dr. Ayanian at the Department of Health Care Policy, Harvard Medical School, 25 Shattuck St., Parcel B, 1st Fl., Boston, MA 02115.
Assessing the Appropriateness of Medical Care
Wassertheil-Smoller S., Tobin J., Steingart R., Hsu J., Black N., Ayanian J. Z., Shekelle P. G., Park R.E., Naylor C. D.
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N Engl J Med 1998;
339:1478-1481, Nov 12, 1998.
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