The overall prevalence of chronic idiopathic constipation(CIC) approximates 15% and up to 24% in those 65 yo. We hypothesize the initial approach (colonoscopy vs. empiric Tx) and choice of firstline and subsequent medical therapies varies greatly despite published guidelines. Purpose: To survey practicing gastroenterologists regarding their firstline and 2o Tx choices for CIC as compared to guidelines (AGA, 2000). Methods: Using the AGA membership, we identified full and trainee domestic practitioners. A SurveyMonkey questionnaire was sent by email on 2 occasions (separated by 1 month) designed with 5 cases, each representing a highly probable scenario for CIC. All cases underwent external review by 2 experts independent of the protocol. The cases varied by age and gender but all described <3 bowel movements / wk for 1 yr after failing fiber Tx. Recent normal colonoscopy was reported for cases 50 yo. We first asked questions related to the initial approach: colonoscopy or empiric Tx. Regardless of their 1st choice, follow-up questions asked for subsequent Tx's including: osmotic laxative (PEG), stimulant laxative (senna), castor oil (CO) or a type-2 Cl channel activator (lubiprostone). Assuming firstline Tx was titrated to higher doses, 2o Tx options included switching or using combination Tx's. Responses were categorized as adhering to current guidelines based on choosing empiric Tx vs. colonoscopy and prescribing PEG. Results: Of 6,182 surveyed, 403 responded [μ=48±11 yo; male 84%; academic 43%, private practice 49%, mixed 8%; μ yrs in practice=15±12 yrs] of which 333 were complete. The table describes Tx recommendations for each case. The odds ratio (OR) for female physicians adhering to guidelines was 2.1(1.1-3.8,95%CI), and 0.5(0.3-0.9) for male physicians. Private practice physicians were less likely to follow guidelines with an OR=0.6(0.4-0.98,95%CI). Conclusion: Regardless of practice setting, empiric Tx was favored for cases with suspected functional bowel disease except for our 41 yo cases. Initial Tx greatly favored osmotic laxatives regardless of the age. Failure of initial Tx resulted in great ambiguity of a dominant 2o Tx strategy. We conclude that there is incomplete adherence to national guidelines that is influenced by physician gender and practice setting.