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.
The appropriate role of generalist and specialist physiciansis a major issue in the debate about the health care systemof the United States1,2,3. Over two thirds of physicians inthe United States are specialists,4 but managed-care plans useconsiderably fewer of them5,6. Recently, national debate hasfocused on ways to increase the proportion of physicians whodeliver primary care,7,8 with the goals of improving access,containing costs, and maintaining the quality of care2. Littleis known, however, about the knowledge and practices of generalistand specialist physicians with respect to the treatment of specificillnesses.
Myocardial infarction is an illness for which both generalistsand specialists deliver care. It is the leading cause of deathin the United States9 and accounts for nearly 700,000 hospitaldischarges annually10. Therefore, physicians' treatment of myocardialinfarction is an important model for assessing the knowledgeand practices of generalist physicians in the fields of familymedicine and internal medicine as compared with those of specialistsin the field of cardiology.
Over the past 30 years, randomized, controlled trials of drugtherapy have produced valuable new insights into the treatmentof myocardial infarction11,12. Such trials have demonstratedclear improvements in survival associated with the use of thrombolyticagents,13,14 aspirin,14,15 and beta-blockers16,17,18 in patientswith myocardial infarction. Conversely, randomized trials havenot shown improvements in survival with the prophylactic useof lidocaine19,20 or the use of calcium-channel blockers21,22,23,24for this condition. Physicians at hospitals that participatein clinical trials may rapidly apply the results of such trialsin their practices,25,26 but data from broader samples of hospitalshave shown that thrombolytic agents are still used in a relativelysmall proportion of patients after myocardial infarction andthat calcium-channel blockers are used more frequently thanbeta-blockers27,28.
Previous surveys of physicians have suggested that the prescriptionpractices of internists and family practitioners differ fromthose of cardiologists,29,30 but this finding has not been uniform31.We surveyed physicians in the states of New York and Texas whohad recently treated patients with acute myocardial infarctionto assess their knowledge and practices regarding drug therapyfor this condition.
Methods
Study Population
We selected New York and Texas because they are large states(together they account for 14 percent of the U.S. population32),they are in different regions of the country, and they are thefocus of an extensive analysis of the costs and outcomes ofacute myocardial infarction by us and others. These two statesalso have different patterns of care for patients with myocardialinfarction; for example, coronary angiography is used much morefrequently to assess patients with myocardial infarction inTexas than in New York (unpublished data).
We obtained the names and addresses of all licensed cardiologists,internists, and family practitioners from the Medical Societyof the State of New York (including both members and nonmembersof the society) and the Texas State Board of Medical Examinersas of January 1993. These organizations update their recordsthrough regular contact with physicians and other professionalorganizations. Before sampling, we excluded physicians who werelisted as retired or in training or who practiced outside thetwo states. The remaining physicians, available for sampling,included 1458 cardiologists, 6863 internists, and 1976 familypractitioners in New York and 619 cardiologists, 3068 internists,and 3346 family practitioners in Texas.
Physicians were considered eligible if they reported servingas the attending or consulting physician for at least one patienthospitalized with acute myocardial infarction during the threemonths before the survey. Our objective was to obtain completedsurveys from at least 1000 eligible physicians, roughly halffrom each state and one third from each of the three fields.This sample would provide the study with a statistical powerof 80 percent to detect an absolute difference of 15 percentin responses between any two fields of practice within one state.
To estimate eligibility and response rates before the full samplewas surveyed, we initially distributed the questionnaire toa randomly selected subsample of 389 physicians. The total randomsample of 4386 physicians (including the initial 389 physicians)comprised 348 cardiologists, 848 internists, and 974 familypractitioners in New York and 316 cardiologists, 788 internists,and 1112 family practitioners in Texas.
Data Collection
We designed a four-page questionnaire to assess physicians'knowledge about and practices regarding drug therapy for myocardialinfarction. We inquired about four treatments in associationwith which randomized trials published in major clinical journalshave demonstrated clear improvements in overall survival; theywere thrombolytic agents administered within 6 hours of theonset of myocardial infarction,13,14 aspirin initiated within24 hours14 and continued as long-term therapy,15 and the long-termuse of beta-blockers16,17,18. We also inquired about two treatmentsthat have not been shown to improve survival in randomized trialsand that may actually reduce survival: prophylactic administrationof lidocaine within 24 hours after the onset of myocardial infarction19,20and diltiazem for patients with Q-wave myocardial infarctionsand pulmonary congestion23,24.
We elicited each physician's beliefs about the effect of specifictreatments on overall survival among patients under 75 yearsof age, based on reported studies. We chose this age limit becausepublished data are less extensive for older patients than foryounger ones. We asked the physicians to choose one of fiveterms to describe the effect of the four treatments: "definitelyimprove survival," "probably improve survival," "no clear effecton survival," "probably worsen survival," and "definitely worsensurvival"; or to answer "not sure." We also asked physiciansto rate the likelihood that they would use each class of drugin patients under 75 years of age with acute myocardial infarction.The choices were "very likely," "somewhat likely," "unlikely,""do not use after myocardial infarction," and "not sure."
We also collected demographic and professional data from thephysicians, including their age and sex, whether they had boardcertification in their primary field of practice, the numberof patients they had treated for acute myocardial infarctionduring the preceding three months, and the number of beds andteaching status of the hospital where they chiefly practiced.
The survey was distributed to the physicians by Northeast Research,a survey firm in Orono, Maine, along with a letter from oneof us describing the purpose of the survey, the federal funding,and the voluntary and confidential nature of the survey. Physicianswho did not respond to the initial mailing within three weeksreceived a second questionnaire by certified mail. The staffof Northeast Research called physicians who did not respondto the mailings, making at least eight telephone calls overa 15-day period to determine each physician's eligibility andwillingness to complete the survey. Finally, a third mailingwas sent to physicians who did not respond within four weeksof the last attempted call.
Eligibility and Response Rates
Of the 4386 physicians to whom we sent questionnaires, 12 haddied. The remaining group of 4374 physicians were in the followingcategories: (a) 1211 were eligible and completed the survey;(b) 319 were eligible but declined to respond or did not returnthe survey; (c) 1818 returned the survey but were ineligible;and (d) 1026 had unknown eligibility and did not return thesurvey. On the basis of the 3348 physicians whose eligibilitywas known (categories a + b + c), we estimate that 45.7 percentof sampled physicians were eligible for the study [(a + b) dividedby (a + b + c)]. When this eligibility rate was applied to thephysicians with unknown eligibility (category d), the overallresponse rate was 60.6 percent33.
The eligibility rates according to field of practice in NewYork and Texas were 79.5 percent and 89.7 percent, respectively,for cardiologists; 40.3 percent and 41.8 percent for internists;and 40.9 percent and 32.9 percent for family practitioners.Among the eligible physicians, the response rates accordingto field in New York and Texas were 64.7 percent and 65.0 percent,respectively, for cardiologists, 54.1 percent and 61.1 percentfor internists, and 64.2 percent and 57.3 percent for familypractitioners.
In Texas, the 593 physicians who completed the survey were similarto the 637 physicians who did not respond in terms of mean age(both 45.9 years, P = 0.90) and the proportions who were men(92.2 percent vs. 90.1 percent, P = 0.19), who had graduatedfrom medical schools in the United States and Canada (81.4 percentvs. 78.5 percent, P = 0.20), and who were practicing in metropolitanareas (83.3 percent vs. 85.4 percent, P = 0.31). Respondentswere slightly more likely than nonrespondents to be non-Hispanicwhites (79.4 percent vs. 74.1 percent, P = 0.05). In New York,only the name, address, and specialty of each physician wereavailable to us, so we could not perform similar comparisonsof respondents and nonrespondents.
Statistical Analysis
All analyses were performed on data from the 1211 completedsurveys from eligible physicians. The demographic and professionalcharacteristics of the physicians in the three fields are presentedaccording to state. For the substantive questions relating toknowledge and practices, the patterns of response accordingto field of practice were similar in the two states; therefore,data have been combined for the two states in the tables, andresults for each state are summarized in the text. Pairwisecomparisons between fields were performed with the Wilcoxonrank-sum test. "Not sure" or missing responses to individualitems were excluded from these analyses. Such responses werereceived from fewer than 5 percent of the respondents for eachof the substantive questions, except for that related to theeffect of diltiazem on survival among patients with a Q-wavemyocardial infarction and pulmonary congestion (14.6 percent).
Multiple logistic regression was used to assess the relativelikelihood that physicians in each field would believe thatthe four beneficial treatments definitely improved survival.For the two ineffective treatments, we calculated the relativelikelihood that physicians would believe that the treatmentprobably or definitely improved survival (neither of these responsesis supported by published data). We also assessed the odds thatphysicians in different specialties would be very likely touse each class of drugs to treat patients with myocardial infarction.All models controlled for the age of the physician (<40,40 through 49, or 50 years), board certification, the numberof patients treated for myocardial infarction in the past threemonths (1 through 4, 5 through 9, or 10), and the number ofbeds (<200, 200 through 499, and 500) in the principal hospitalin which the physician treated patients for myocardial infarctionand its teaching status (university, university-affiliated,or community hospital).
Analyses were conducted with SAS statistical software34. Individualphysicians were identified only by a confidential study number.Two-tailed P values are reported for descriptive statisticsand 95 percent confidence intervals for adjusted odds ratios.
Results
Characteristics of the Physicians
The characteristics of the responding physicians in each fieldare presented in Table 1. In New York, but not in Texas, familypractitioners were younger, on average, than physicians in theother two fields and more likely to be board certified in theirspecialty. As compared with internists and family practitioners,cardiologists in each state had recently treated more patientswith acute myocardial infarction. In both states, family practitionerswere more likely than cardiologists to work in community hospitalsand smaller hospitals; internists occupied an intermediate positionbetween the other two groups.
Table 1. Characteristics of the Responding Physicians According to State and Field of Practice.
Beliefs about Drugs
For the four drug therapies that are known to increase survival,cardiologists believed more strongly than internists and familypractitioners that treatment improved overall survival aftermyocardial infarction (Table 2). With respect to thrombolyticagents, 93.1 percent of cardiologists believed therapy definitelyimproved survival, as compared with 85.4 percent of internistsand 80.7 percent of family practitioners; for the immediateuse of aspirin, these figures were 75.9 percent, 52.4 percent,and 44.7 percent; for the long-term use of aspirin, 71.6 percent,54.6 percent, and 50.0 percent; and for the long-term use ofbeta-blockers, 75.3 percent, 54.2 percent, and 51.6 percent.Conversely, for the prophylactic use of lidocaine and the useof diltiazem for patients with Q-wave myocardial infarctionand pulmonary congestion, cardiologists were less likely thaninternists and family practitioners to believe these treatmentsimproved survival. Among cardiologists, 10.9 percent thoughtthat prophylactic lidocaine definitely or probably improvedsurvival, as compared with 34.0 percent of internists and 40.2percent of family practitioners; for the use of diltiazem, thesefigures were 2.3 percent, 5.8 percent, and 16.5 percent. Asshown in Table 2, beliefs about the efficacy of drugs did notdiffer significantly between internists and family practitioners,except for the immediate use of aspirin (P<0.03) and theuse of diltiazem for patients with Q-wave myocardial infarctionsand pulmonary congestion (P<0.001). In both cases, internists'beliefs fell between those of cardiologists and family practitioners.
Table 2. Beliefs of Physicians in New York and Texas about the Effect of Drugs on Survival among Patients under 75 Years of Age with Acute Myocardial Infarction, According to Field of Practice.
In analyses stratified according to state, the differences betweencardiologists and the other two groups of physicians were significant(P<0.05) in both New York and Texas for all but one of thesix therapies. In Texas, internists were similar to cardiologistsin their beliefs about the effects of early thrombolytic therapy(P>0.10).
In the logistic-regression models, the field of practice remaineda significant predictor of beliefs (Table 3). After we adjustedfor age, the number of patients treated recently who had acutemyocardial infarction, the hospital's size and teaching status,and the state, cardiologists were more likely than both internistsand family practitioners to respond that early thrombolytictherapy, the immediate and long-term use of aspirin, and thelong-term use of beta-blockers definitely improved survival.Cardiologists were less likely than the physicians in the othertwo groups to believe that prophylactic lidocaine and diltiazemdefinitely or probably improved survival.
Table 3. Adjusted Odds Ratios for Beliefs about the Effect of Drugs on Survival, According to Field of Practice.
Age was a significant predictor of beliefs in the multivariatemodel. Physicians under 40 years of age were more likely thanolder physicians to believe in the value of the four therapiesthat genuinely improve survival and less likely to believe inthe value of prophylactic lidocaine and diltiazem (P 0.05).Board certification, the number of patients with myocardialinfarction that each physician had treated recently, and thesize and teaching status of each physician's principal hospitalwere not consistently significant predictors in the logistic-regressionmodels.
Prescription Practices
The physicians' reports of their prescription practices wereconsistent with their beliefs about the effects on survivalof each class of drugs (Table 4). Cardiologists were more likelythan internists and family practitioners to state that theywould prescribe thrombolytic agents (94.1 percent said theywere very likely to prescribe such agents, as compared with82.0 percent and 77.3 percent, respectively), aspirin (98.7percent, 91.3 percent, and 89.8 percent), and beta-blockers(77.5 percent, 63.0 percent, and 53.1 percent) for patientswith acute myocardial infarction; cardiologists were least likelyto report that they would use prophylactic lidocaine (4.7 percent,13.1 percent, and 16.5 percent) and calcium-channel blockers(11.2 percent, 22.6 percent, and 26.0 percent). All these differenceswere significant (P 0.05) in stratified analyses in each stateand in multivariate analyses (Table 5).
Table 4. Drug-Prescription Practices of Physicians in New York and Texas Treating Patients under 75 Years of Age with Acute Myocardial Infarction, According to Field of Practice.
Table 5. Adjusted Odds of Prescribing Specific Drugs for Patients with Myocardial Infarction, According to Field of Practice.
In the full sample (Table 4), internists were more likely thanfamily practitioners to report prescribing beta-blockers (P<0.01),a difference that was significant in each state (P<0.05).Internists were less likely than family practitioners to reportprescribing prophylactic lidocaine when we analyzed the fullsample (P<0.02), but this finding was significant only inTexas (P<0.001), not in New York.
Use of Beta-Blockers
Beliefs and practices were generally similar among physiciansin the two states, but within each field of practice more physiciansin New York than in Texas believed that beta-blockers definitelyimproved survival (P<0.05). Accordingly, for each specialty,a larger proportion of physicians in New York than in Texasreported that they were very likely to prescribe beta-blockers(P<0.001); the proportions ranged widely, from 88 percentof cardiologists in New York to 37 percent of family practitionersin Texas (Figure 1). The state was a significant predictor ofbeliefs and practices regarding beta-blockers in the multivariatemodels (P<0.001).
Figure 1. Proportion of Physicians Who Reported That They Were Very Likely to Prescribe Beta-Blockers as Long-Term Therapy for Patients under 75 Years of Age with Acute Myocardial Infarction, According to State and Field of Practice.
Discussion
Our survey of physicians in New York and Texas demonstratesthat internists and family practitioners are less aware thancardiologists of the results of studies of the effect of importantdrugs on survival after myocardial infarction, or less certainabout such results. Most striking was the finding that onlyabout half of internists and family practitioners believed thatthe immediate and long-term use of aspirin and the long-termuse of beta-blockers definitely improved survival, as comparedwith roughly three quarters of cardiologists. These variationsin beliefs were associated with significant differences amongthe fields in the prescription of each class of drugs, and thepatterns were consistent in each state.
Three factors may explain the differences in beliefs and practicesbetween generalist and specialist physicians. First, internistsand family practitioners may have less knowledge than cardiologistsof the results of key clinical trials. Physicians maintain andrefine their clinical knowledge by reading journals and textbooks,through discussions with colleagues, and through participationin conferences and continuing-education courses35,36,37. Cardiologistsare better able than primary care physicians to focus theirlearning by these methods on myocardial infarction, since cardiologiststreat patients for a narrower range of clinical problems thando internists or family practitioners. The major published guidelinesfor the treatment of myocardial infarction in the United Stateshave appeared in journals that target cardiologists38,39; primarycare physicians may also benefit from such guidelines.
A second explanation could be that physicians in generalistfields have greater concern about therapeutic complications,such as bleeding after thrombolytic therapy or congestive heartfailure due to beta-blockers. Probably because aspirin is viewedas the most benign of the drugs in this study, 9 out of 10 internistsand family practitioners who responded said they were very likelyto prescribe aspirin after myocardial infarction -- even thoughonly half believed that it definitely improved survival. However,this factor does not explain the greater willingness of internistsand family practitioners to use prophylactic lidocaine and calcium-channelblockers, both of which can have important and occasionallylethal side effects.
A third explanation could be that generalist physicians mayexercise greater caution than specialists in accepting new dataor changing established patterns of treatment40. Some cardiologistsmay share this caution, as demonstrated by the one quarter whosaid they did not believe that aspirin and beta-blockers definitelyimproved survival after myocardial infarction. Even clinicalexperts can be slow to incorporate the results of clinical trialsinto their published recommendations41.
The relation of the age of physicians to their beliefs aboutdrug therapy suggests that younger physicians have had morerecent or more concentrated exposure to the results of relevantclinical trials than older physicians or that they may be morereceptive to new standards of practice42. Physicians in NewYork were more likely than those in Texas to say they believedthat beta-blockers improved survival after myocardial infarctionand to use them for patients with this condition; this findingsupports other studies that have demonstrated geographic variationsin medical care43,44. The number of patients that each physicianhad recently treated for myocardial infarction was not a consistentlysignificant predictor in the multivariate models. However, ourability to assess this variable was limited because it was closelycorrelated with field of practice.
Our study had several strengths. We found consistent resultsin a large sample of physicians from two regions of the UnitedStates. We focused on physicians who had recently treated patientsfor acute myocardial infarction, and the response rate was substantiallyhigher than in other published surveys of physicians,30,45 thusreducing the possibility of bias related to the characteristicsof nonrespondents.
This study has at least three limitations. First, the data onprescription practices are based on reports by physicians, notdata from medical records. Second, some physicians may havebased their answers on the limited clinical detail providedin the survey questions. For example, specifying the presenceof ST-segment elevation might more accurately elicit beliefsabout the effect of thrombolytic therapy on survival, and specifyingthe level of ventricular function might influence the responsesto questions about the likelihood of prescribing calcium-channelblockers. Third, we expect that more appropriate use of drugsresults in better clinical outcomes,46 but our data do not addressthis issue. In preliminary data from a study of patients withunstable angina, internists were less likely than cardiologiststo use aspirin and beta-blockers in clinical practice, and mortalityamong patients treated by internists tended to be higher47.
Many internists and family practitioners are aware of the resultsof published clinical trials and meta-analyses of therapy formyocardial infarction and apply these results in their practices.On average, however, generalist physicians appear to be lessaware of or less certain about these results than are specialists.A number of factors may improve the knowledge and practice patternsof physicians,48,49 including continuing-education programs,broader dissemination of guidelines, more rigorous recertificationprocedures, provision of feedback about clinical practices,and participation in community-based clinical trials. A multifacetedapproach to increasing physicians' knowledge of trial resultswill help to ensure that important lessons from research areapplied to medical care in an appropriate and timely manner.
Supported by a Patient Outcomes Research Team grant (HS06341)from the Agency for Health Care Policy and Research. Dr. Ayanianis a Generalist Physician Faculty Scholar of the Robert WoodJohnson Foundation.
We are indebted to Michael Elliott and David Kovenock of NortheastResearch for administering the survey, to Alison Eastwood andBud Davies for statistical programming, to Brian Egleston forassistance in the preparation of the manuscript, and to AnthonyL. Komaroff, M.D., and Thomas J. Ryan, M.D., for helpful commentson an earlier draft of the manuscript.
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.
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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.
Correspondence
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50 years), board certification, the number of patients treated for myocardial infarction in the past three months (1 through 4, 5 through 9, or 
0.05). Board certification, the number of patients with myocardial infarction that each physician had treated recently, and the size and teaching status of each physician's principal hospital were not consistently significant predictors in the logistic-regression models. 
-Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results. JAMA 1982;247:1707-1714. 
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