22HSR DO INTERNISTS AND FAMILY PRACTITIONERS DIFFER IN THEIR DIAGNOSIS AND MANAGEMENT OF THE SAME PATIENT WITH HEART DISEASE?

Sunday, October 18, 2009
Grand Ballroom, Salons 1 & 2 (Renaissance Hollywood Hotel)
Rebecca Shackelton, ScM1, Carol L. Link, PhD2, Lisa D. Marceau, MPH2 and John B. McKinlay, PhD2, (1)New England Research Institutes, Inc., Watertown, MA, (2)Neri, Watertown, MA

Purpose: Many reports have detailed differences in the process and cost of care provided by Internal Medicine (internists) and Family Practice (FP) physicians. In this study, we examine the differences between internists and FP physicians on the diagnosis of coronary heart disease (CHD) and on physicians’ decision making (their proposed clinical actions).

Method: As part of two studies (study 1, n=128; study 2, n=256) we presented primary care doctors with identical clinically authentic filmed vignettes of a “patient” presenting with CHD. Their proposed clinical actions were compared based on the physicians’ self-classification as either an internist or FP.

Result: There were 192 self-labeled FP physicians (50.0%), 175 internists (45.6%) in our sample of 384 primary care physicians (17 otherwise unspecified general practitioners were removed from these analyses). There was no difference between IM and FP physicians in the diagnosis of CHD (97% of patients were diagnosed with CHD regardless of primary care focus). However, internists were more certain about the correct diagnosis of CHD (60.9 on a scale of 0-100 with 100 being the most certain) than FP physicians (53.7, p=0.005). FP physicians were more likely to make an incorrect mental health diagnosis (80.2% vs. 75.7% for internists) and were more certain of that diagnosis (44.7 vs. 37.2 for internists, p = 0.03). In terms of management, FP physicians asked more questions (11.6 questions on average) than internists (8.5, p<0.001) especially questions about family history (71.4% vs. 37.7% for internists, p<0.001). FP physicians gave more lifestyle advice (4.2 pieces of advice on average) than internists (3.1, p < 0.001) including advice about exercise (36.5% vs. 17.7%, p<0.001) and alcohol (25.5% vs. 14.9%, p=0.01). FP physicians were more likely to refer the patient to a cardiologist (32.8% vs. 19.4%, p=0.004). Internists were also more likely to order a stress test (68.0% vs. 46.9%, p<0.001) and prescribe beta blockers (28.6% vs. 17.2%, p=0.009).

Conclusion: There are clear differences in the way physicians handle a hypothetical case of CHD depending upon their primary care training. We found that FP physicians were more likely to ask questions and give advice while internists were more certain on the correct diagnosis of CHD and were more likely to conduct examinations and prescribe medications.

Candidate for the Lee B. Lusted Student Prize Competition