Years in practice may correlate with training in two ways: (1) family practice residencies did not exist until less than 20 years before this survey was taken, and (2) physicians who have been out of training longer may be less likely to consider themselves competent to perform the exercise stress tests (if they have not been doing the procedure).
Residency programs are the primary source of training for physicians who perform exercise stress tests, but a large percentage of respondents in this study learned the procedure on the job or in continuing education courses.
Documentation of ischemia-induced electrocardiographic ST segment changes, which form the basis of exercise stress testing, dates to the beginning of this century, when Einthoven produced an electrocardiogram that revealed postexercise ST depressions. Since Feil and Siegel performed what is generally considered the earliest exercise stress test in 1928 by reproducing ST-T wave changes consistent with ischemia, the exercise stress test has become an essential procedure for diagnosing coronary artery disease.
Family physicians, who manage 26% of all patients with known coronary artery disease,[2-3] are a logical group to counsel patients about coronary risk factors and to diagnose coronary artery disease using the standard exercise stress test. There is considerable debate, however, regarding whether family physicians should do exercise stress testing themselves or refer patients to specialists for the procedure.
It should be noted, however, that the average number of exercise stress tests performed by residents in both groups (internal medicine 39.1, family practice 24.4) was well above average suggested minimums.
Comments provided by the program directors indicated that residents were more likely to be pursuing training in exercise stress tests if they were planning to go into general practice or to a rural area.
Zoller and Boyd(24) described their experience with 265 exercise stress tests performed by family practice residents during a 6-year period.
Clearly a number of family physicians are performing exercise stress tests safely and effectively in their practices.