Variations in the processes and quality of medical care in the United States have been extensively documented and are a major concern for health services researchers and policy experts (Institute of Medicine, 2003
). Research to date has ranged from describing area variations between national health care systems and geographic regions (McKinlay et al., 2006
), to differences between practice settings and organizational cultures, (Shackelton, Link, Marceau, & McKinlay, 2009
), to the often more subtle influence of patient attributes, (i.e. between race/ethnic groups and by gender, age and socio-economic status) (Arber et al., 2004
; Institute of Medicine, 2003
; McKinlay et al., 1997
). Some studies have focused on the influence of physician characteristics, such as gender, age/clinical experience and medical specialty (Burns et al., 1997
; McKinlay, Lin, Freund, & Moskowitz, 2002
). Differences between
medical specialties in the diagnosis and management of illness conditions have been reported and are commonly attributed to differences in treatment philosophy, training, and personality type (Greenfield, Nelson, & Zubkoff, 1992
). That variations may also occur within
a medical specialty, for example between general internists and family practitioners within
primary care, has received little attention. What occurs at the level of primary care is important for several reasons; a) it is the gateway to the healthcare system, crucially determining the course of many diseases, costs and patient outcomes; b) it is where the vast majority of illness in society is presented and cared for; c) it may be the point of origin for the generation and amplification of many reported disease disparities; (McKinlay et al., 2007
; McKinlay, Potter, & Feldman, 1996
) and d) it may also be the point of origin for ever increasing costs of health care, given the suggestion that the most expensive piece of medical technology may be a physicians’ pen (Gawande, 2009
; Noren, Frazier, Althman, & DeLozier, 1980
Differences in clinical practice between general internists and family practitioners may begin during medical residency. Internal medicine residency training is largely based in the inpatient setting (Holmboe et al., 2005
; Weinberger, Smith, & Collier, 2006
). Internal medicine residents spend about 10 percent of their training time in ambulatory settings, whereas family practice residents spend about 30 percent in such settings (Cherkin, Rosenblatt, Hart, Schneeweiss, & LoGerfo, 1987
). Family practice training programs devote considerably more attention and time to psychosocial issues (Gaufberg et al., 2001
). Gaufberg and colleagues suggest family practice and internal medicine have distinct perspectives, employing different explanatory models of “disease”—family practice is grounded in a biopsychosocial framework whereas internal medicine appears more pathophysiologically (biomedically and subspecialty) oriented (Gaufberg et al., 2001
Differences between internists and family practitioners have received little attention, despite their importance for understanding variations in diagnostic accuracy and certainty, costs, the quality of health care and patient outcomes. Internists reportedly perform more detailed physical examinations and order more laboratory tests which contributes to-increasing health care costs, although it has been suggested internists may also encounter sicker patients with more complicated medical problems (Conry, Pace, & Main, 1991
; Kravitz et al., 1992
). Family practitioners appear to ask more questions concerning a patient’s emotional status and life situation (Cherkin et al., 1987
; Noren et al., 1980
; Smith & McWhinney, 1975
This paper examines differences between internists and family practitioners in their diagnosis and management of exactly the same “patient” presenting with the signs and symptoms strongly suggesting coronary heart disease (CHD). We attempt to avoid methodologic limitations of work to date on medical specialty differences related to differences in medical setting, types of patients, case mix, resources, and health care system (Kravitz et al., 1992
). While some differences in practice style and resource utilization between internists and family practitioners have been examined, possible differences in diagnostic preferences and processes of care between these two groups have received little attention.
We employ data from a random sample of community-based primary care physicians (PCPs) to addresses the following questions: First, are there any differences between internists and family practitioners in their suggested diagnoses and level of diagnostic certainty when encountering exactly the same “patient”? Second, are there any noteworthy differences in the processes of care between internists and family practitioners, particularly with regards to testing and prescriptions? These questions have important implications for reported disparities in disease rates, health care variations, the increasing costs of health care and even patient outcomes.
Most research to date on differential PCP decision making has been plagued by confounding, since internists may see sicker patients and are thought to encounter more complicated medical problems (Kravitz et al., 1992
). In our study all primary care physicians saw a “patient” with exactly the same signs and symptoms, thereby completely eliminating confounding due to the severity of illness. There may also be differences by gender and age/clinical experience, which may affect the interpretation of any differences between internists and family practitioners. Our research design permitted us to control for any such differences. Further, many prior studies were performed at single sites, whereas our study utilized a random sample of physicians from different geographic locations.
Gaufberg and colleagues suggest family practice and internal medicine have distinct perspectives, emphasizing different explanatory models of “disease”—family practice is grounded in a biopsychosocial framework whereas internal medicine is more pathophysiologically (biomedically and subspecialty) oriented (Gaufberg et al., 2001
). These conceptual differences are manifested in residency training as discussed above. Differences in training may also contribute to differing diagnostic practices and reactions to clinical uncertainty. The question is: do these suggested differences in the training and perspective of internists and family practitioners eventually manifest themselves in differences in diagnosis, clinical uncertainty and processes of care relating to clinical management?