Second, clinicians must be motivated to alter their practice in light of new evidence. Although clinician age, gender, and year of graduation appear to be associated with practice variation in some, but not all, studies, it is recognized that prescribing patterns (and sometimes clinical outcomes) do vary by physician specialty, even after adjusting for differences in case mix (17). Of note, although there is a relatively rich database documenting differences between specialties in the management of hospitalized patients with acute myocardial infarction (MI) or HF (17- 19), the evidence base is less robust for differences in outpatient care and is an area of active research (20- 21). Although being aware of new evidence is a prerequisite to changing practice, studies examining physician knowledge while simultaneously measuring clinical practice have found remarkably consistent gaps between what we know and what we do, with a median absolute difference of 28% (22). Further, although both specialists and generalists tend to over-estimate the baseline risks of their patients (23- 24), and at least two surveys have demonstrated that both groups estimated similar relative benefits for specified therapies, non-specialists tended to substantially over-estimate potential side-effects (25- 26). As a further example, while over 60% of European primary care physicians were aware of the survival benefits of beta-blockers in HF, two-thirds expressed reluctance to prescribe these agents without specialist input, and only 21% of beta-blocker prescriptions were initiated by the primary care physician (6). The reluctance of primary care physicians to apply new evidence (“therapeutic conservatism”) may be partially attributable to the fact that patients seen in primary care are often older and have more unrelated co-existing illnesses than the patients seen by specialists or the subjects entering RCTs (19).