Objectives This study sought to assess the impact of generalist versus specialist direction on the pattern of care and outcome in patients admitted to the hospital for unstable angina. Background Physicians trained as internists or as cardiologists may have different approaches to treating patients with unstable angina. Methods We reviewed a prospectively collected cohort of patients discharged with a diagnosis-related group (DRG) diagnosis of unstable angina from William Beaumont Hospital, a large community-based hospital in southeast Michigan. Of 890 consecutive patients, 225 were treated by internists and 665 by cardiologists. We compared these two groups with respect to patterns of use of established pharmacotherapies for unstable angina, diagnostic testing and clinical outcome. Results Patients treated by internists less often had a previous cardiac history (53% vs. 80%, p ≤ 0.0001). Internists were less likely to use aspirin (68% vs. 78%, p = 0.032), heparin (67% vs. 84%, p ≤ 0.001) or beta-adrenergic blocking agents (18% vs. 30%, p ≤ 0.004) in their initial management. Exercise tests were performed more frequently by internist-treated patients (37% vs. 22%, p ≤ 0.001), but catheterization (27% vs. 61%, p ≤ 0.0001) and angioplasty (7% vs. 40%, p ≤ 0.0001) were utilized less frequently. The incidence of myocardial infarction was similar (11% vs. 9%) in the two groups, but the mortality rate tended to be higher (4.0% vs. 1.8%, p = 0.06) in the internist group. Conclusions Patients with unstable angina treated by internists were less likely to receive effective medical therapy or revascularization procedures and experienced a trend to poorer outcome. This study does not support a positive gatekeeper role for generalists in the treatment of unstable angina.