Background: Influenza and pneumococcal vaccination rates remain too low. This survey assessed generalist and subspecialist physicians' knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for high-risk patients. Methods: A self-administered questionnaire was mailed to 6000 physicians randomly selected from a national database. Results: After 3 mailings, 1874 physicians (32%) of the 5858 eligible responded. Although most physicians thought that it was very important for their high-risk patients be current on influenza and pneumococcal vaccinations, only 86% and 75% of generalists and subspecialists, respectively, very strongly recommended influenza vaccinations to their elderly patients and only 81% and 64%, respectively, very strongly recommended pneumococcal vaccinations to their elderly patients (P<.001 for both). After multivariate logistic regression, factors significantly associated with strongly recommending vaccinations to elderly patients in the influenza and pneumococcal vaccination models included female sex of provider, the provider having received an influenza vaccination, the provider's beliefs about vaccine effectiveness and cost-effectiveness, a patient's risk for illness, and ease of targeting patients. In addition, generalists were more likely than subspecialists to strongly recommend pneumococcal vaccinations to their patients. Patient reminders, special clinics, and standing orders were each used by fewer than 30% of respondents, although generalists were more likely than subspecialists to use such strategies. Conclusions: Nontrivial proportions of generalist and subspecialist physicians fail to strongly recommend influenza and pneumococcal vaccinations to their elderly and high-risk patients. Other effective strategies for promoting vaccine delivery are also used relatively infrequently. These findings suggest areas for improvement if vaccination rates are to reach national goals.