Managing chest pain patients in general practice: an interview-based study

Managing chest pain patients in general practice: an interview-based study Background: Assessment of chest pain in general practice is challenging. General practitioners (GPs) often feel uncertainty when dealing with chest pain. The role of new diagnostic tools is yet unclear. Therefore, we aimed to learn: (1) whether or not GPs experience a change in incidence and presentation of chest pain, (2) how GPs deal with uncertainty, and (3) which thoughts, demands and doubts concerning new diagnostic tools occur. Methods: Semi-structured, face to face interview based study, aiming at six main subjects: experienced changes in prevalence of chest pain, the management of chest pain patients, dealing with uncertainty, the GPs’ approach in referring chest pain patients, GPs’ attitude towards ‘unnecessary’ referrals, and the GPs’ suggestions for improving the management of chest pain patients. Results: 145 GPs in Belgium and the Netherlands were invited to participate, 27 (15 Flemish and 12 Dutch) GPs were interviewed. Data saturation was reached. The number of patients having an acute coronary syndrome among chest pain patients is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. GPs rely on their own judgment above all, and desire new diagnostic tools only when these tools are of proven added value. Conclusion: The incidence of chest pain in general practice is not decreasing according to the GPs. However, the presentation of chest pain is changing. GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe. Uncertainty is regarded as a substantial element of their profession. New diagnostic tools are awaited with cautiousness. Keywords: General practice, Cardiovascular disorders, Diagnostic tests, Urgent care, Risk assessment Background and less severe causes of chest pain, based on clinical find- Chest pain in general practice ings or electrocardiography, is difficult [5–8]. In general practice, chest pain as a reason for encounter is common (prevalence 1–3%) and differential diagnosis The challenge of (not) referring patients with chest pain is broad [1, 2]. Yet, in only a minority, an acute life threat- Most guidelines clearly state that general practitioners ening disease is concerned. Severe diseases as acute cor- (GPs) should refer every patient suspected of an ACS to onary syndrome (ACS), pulmonary embolism or thoracic secondary care facilities as soon as possible, or GPs aortal dissection are outnumbered by non-urgent causes should even be bypassed to prevent loss of time and, as gastro-esophageal reflux disease (GERD) or thoracic consequently, myocardial cell necrosis [9]. However, for wall pain [1, 3, 4]. However, discriminating between ACS every chest pain patient with a life threatening disease as ACS, a GP encounters 11 patients with chest pain of a * Correspondence: robert.willemsen@maastrichtuniversity.nl Leen Biesemans, Lotte E. Cleef and Robert T. A. Willemsen contributed non severe cause [1]. Therefore, clinical judgement and equally to this work. triage by GPs remains inevitable to prevent unnecessary Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO referrals and to keep the burden on secondary care facilities box 616), Maastricht 6200, MD, the Netherlands Full list of author information is available at the end of the article acceptable [3, 10]. To reach this goal, GPs compromise © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Biesemans et al. BMC Family Practice (2018) 19:80 Page 2 of 9 between adequate detection of severe disease on the one especially in the field of patients presenting with chest hand and reassurement in cases of worried patients with no pain [30]. However, a CDR safely reducing referrals is or mild underlying disease on the other hand [6, 11, 12]. lacking [31]. Over time, GPs seem to have found an optimum. They refer only a minority of chest pain patients, thereby ad- Objectives equately maintaining their gatekeeping role. Still, a consid- Studies on GPs’ contemporary perceptions, attitudes and erable number of patients with chest pain (approximately experiences in dealing with chest pain patients regarding 20–40%) are referred for safe exclusion of ACS, whereas uncertainty and developments in presentation, incidence only one out of five of these referred patients suffer from and diagnostic tools as described above are mainly dealing severe disease [1, 13, 14]. Besides classical clinical findings, with specific diseases, are focussing on out of office hours GPs use gut feeling and background knowledge of their pa- working situations or are lacking [16, 17, 32]. Therefore, tients to make these challenging referral decisions [15]. in our study, we aimed to explore the following topics: Uncertainty when dealing with chest pain (1) Do GPs experience a changing incidence and Notwithstanding this strategy to work with low thresh- presentation of chest pain and / or ACS in daily olds for referral to maintain the number of missed cases practice, and if so, what changes do GPs observe? of ACS low, uncertainty among GPs has been a part of (2) Which considerations are important to GPs and dealing with chest pain in general practice for decades how do they deal with uncertainty (regarding [16–18]. GPs regard guidelines as only partially solving referrals of patients without a life threatening their dilemmas in assessing chest pain patients and as disease as well as missed cases of severe disease) in suboptimally answering their questions whether or not the management of chest pain patients? to refer these patients [16]. As a possible consequence, (3) Which thoughts, demands and doubts concerning guidelines do not integrally lead to behavioural change new diagnostic tools can be extracted from GPs’ [19]. Besides, referring patients without consultation – reflections on managing patients with chest pain? for example based on a typical pattern presented in a (This final question was addressed only in the phone call, as is advertised in cases of suspected stroke Dutch interviews, since most Flemish GPs have no – is impracticable in cases of chest pain due to the broad experience with such tools). differential diagnosis [20]. Cautious GPs that are anxious about the consequences of missing severe disease refer Methods more often to secondary care facilities, especially when Inclusion working in out of office hours services [21, 22]. Espe- 145 GPs were selected from a list of GPs who had indi- cially during consultations during out of office hours, cated earlier they were interested in participating in maintaining a threshold for referral is challenging [17]. scientific studies. We invited 15 Flemish GPs by phone and 30 per e-mail. 100 Dutch GPs were invited per Developments in the field of chest pain in general e-mail and were phoned shortly afterwards to inquire practice possible participation. We included general practitioners Several developments in the field of chest pain in general willing to participate, with at least 5 years of working practice have been described. First, an altering presenta- experience. No further selection criteria were used. tion of ACS in general practice has been reported, whether or not due to sex differences in presentation Interview [5, 23–25]. Second, incidence of ACS among chest The semi-structured face-to-face interview, composed pain patients in general practice seems to be declining by the Flemish researchers, consisted of five main sub- over the years (from approximately 20% to less than 10%), jects to answer the objectives of the study: (1) recently mortality has decreased strongly, and prognosis has im- experienced changes in the prevalence of chest pain and proved [1, 26, 27]. Besides absolute data on this topic ad- ACS, (2) management of chest pain patients in daily dressed in quantitative studies, a GP’s perception of a practice, (3) dealing with uncertainty, (4) the GPs’ approach possible changing incidence of ACS is important, since a in referring chest pain patients, and (5) their attitude to- GP’s estimation of the probability of an ACS when asses- wards - in the light of the final diagnosis - ‘unnecessary’ re- sing patients presenting with chest pain (the ‘pre-test ferrals. The second subject (2) was approached by letting probability’) is influenced by this perception [28, 29]. the GPs imagine a chest pain patient and thereby reflect on Third, several diagnostic studies have recently evaluated their diagnostic steps and decision to refer. An additional the role of new diagnostic tools – e.g. clinical decision subject was added in the Dutch interview: (6) the GP’sown rules (CDRs) and point-of-care tests (PoCTs) – in man- suggestions for improving the management of chest pain aging chest pain patients. GPs in Europe desire a PoCT patients in general practice. The interview protocol was Biesemans et al. BMC Family Practice (2018) 19:80 Page 3 of 9 piloted with a Flemish and a Dutch GP who both had over Ethics 25 years of working experience. Flaws were discussed by All participants were informed about the aims of the the researchers and two GPs, which resulted in an adapted study and the recording of the interviews. The study was version of the interview. The pilot interviews were not in- approved by the Medical Ethical Committees of the Uni- cluded in the final research sample. The main questions, versity of Leuven and of Maastricht University. used as starting points of different phases of the interview are given in Additional file 1. Additional questions were not Results predefined, further answers and themes were initiated by 145 (45 Flemish, 100 Dutch) GPs were invited to partici- the GPs themselves. The interviews took place at the GPs’ pate, 27 GPs (15 Flemish and 12 Dutch) were inter- practices, incidentally in a GP’sprivate home. viewed. The main reason for declining our invitation was a lack of time. GP characteristics are presented in Table 1. During the interviews, all GPs commented ex- Data collection tensively on the questions concerning this study’s main Data were collected through face-to-face interviews. three objectives. All interviews lasted 45 to 60 min, inci- Flemish interviews were carried out by LB, as part of her dentally an interview lasted 75 min. research thesis completing her GP education, between June and October, 2015. Dutch interviews were carried Incidence and presentation of chest pain in general out by LC and BH, both fulfilling their research intern- practice (objective 1) ships during the master phase of their medical school, Most GPs stated that they are confronted with chest between April and June, 2016. All interviews were pain at least once every week. Chest pain can have a audio-recorded and transcribed verbatim. Data were col- wide variety of causes, of which the majority is not of lected until saturation was achieved. Saturation was de- cardiac origin. fined as the identification of no new nodes in the last two interviews in the Flemish, or the Dutch part of the “Hm, I think we are confronted with this study, respectively. complaint weekly, maybe even multiple times a week.” [NLGP12] Data analysis Thematic analysis was used to bring forth answers to Table 1 Characteristics (gender, age, years of experience, type the main objectives of this study. All Flemish interview and area of practice) of the participating GPs transcripts were analysed independently by two re- Dutch Flemish Total searchers in a process of inductive line-by-line coding. Gender Male 8 10 18 LB coded all transcripts, and four GP residents and one Female 4 5 9 anesthesiology resident coded three transcripts each. Age groups 35–39 1 2 3 Afterwards, differences were discussed and further ana- lysis was assisted by FB and WR. Thereafter, the initial 40–44 4 0 4 codebook was established, which was adjusted after 45–49 0 4 4 every four interviews. In a second step the codes were 50–54 1 2 3 refined, resulting in the development of descriptive 55–59 5 2 7 themes. Finally, a thematic analysis was performed by all 59–65 1 4 5 researchers to generate new analytical themes. >65 0 1 1 Each Dutch interview was analysed and coded inde- pendently using the Flemish codebook by LC and BH. Years of experience 20.6 (2.5–36) 26.7 (10–40) 24.0 (2.5–40) Conflicts were solved by discussion. During the analysis Type of practice Single 4 4 8 of subsequent interviews, the initial code list was further Duo 5 4 9 refined by adding new codes under the pre-existing Group 3 7 10 themes, when confronted with relevant data that could Area of practice Urban 8 6 14 not be linked to an existing code. Finally, a framework Rural 4 9 13 analysis was performed by LC, BH, and RW to generate new hypotheses. Ultimately, Flemish and Dutch results Through purposive sampling we aimed to attain a heterogeneous group, including both female and male GPs, GPs working in both rural and urban were independently analysed and discussed by LB, LC regions and in single, duo and group practices. One participating GP had only and RW to uncover similarities and differences in out- 2,5 years of experience. Yet the data derived from this interview were maintained, since these were in line with the data from the more experienced comes. Subsequently, these findings were documented GPs. Single, duo, group practices refer to GP practices managed by when applicable in the results section of this paper. respectively one, two and more GPs. Abbreviations: GP general practitioner, N NVivo 11 pro software was used to facilitate coding. number. Mean followed by the range in brackets Biesemans et al. BMC Family Practice (2018) 19:80 Page 4 of 9 “Yes, the lion’s share here, of people presenting with obediently go to the GP. On the other hand, in the chest pain, is not of cardiac origin.” [NL GP 8] city of Mechelen e.g., the citizens – and certainly the immigrants – go to the emergency department much Although some Dutch GPs experienced an evident easier and will thus pass us by.” [BE GP6] increase in the prevalence of chest pain in their practice, the majority of GPs did not experience a change in fre- quency over time. However, most GPs experienced a Assessment of chest pain and dealing with uncertainty change in the clinical spectrum of chest pain. GPs claimed (objective 2) to encounter less cases of ACS, due to improved cardio- When confronted with a chest pain patient, GPs quickly vascular risk management in general practice, and more attempt to distinguish between acute and non-acute path- atypical thoracic complaints, due to a growing awareness ology. The most important tools in assessing chest pain on chest pain in the general population. The anxiety ac- are history taking, clinical evaluation and gut feeling. The companying this awareness, combined with the continu- language used by GPs suggests a feeling of responsibility. ously available health care in large out-of-hours general practice facilities, lower the threshold to consult a GP. “Yes, you first try to determine in which framework the pain fits. (…) Are the lungs causing the problems, or is “Then I think it is more or less the same … if you don’t it the heart or is it something less serious? So that’s only count cardiac but also other types of chest pain what you try to assess first and foremost.” [BE GP10] like respiratory infections or indeed psychosomatic symptoms. Then I think it [the frequency of chest pain] “But I taught myself, if I have a certain gut feeling that is comparable to before.” [BE GP 4] something isn’t right, yes, then I just refer them. I’m not going to take the risk behind the patient’s back.” “I think that the frequency with which we see a grave [NL GP 11] acute infarction nowadays is a lot lower than it was twenty years ago.” [BE GP 7] Most GPs questioned the value of diagnostic tools such as ECG or troponin in ruling out ACS at first assessment. Most GPs believed raising awareness in the general However, a few GPs felt confident enough to not refer a population on the possible consequences of chest pain is patient based on a negative ECG. In non-acute situations, important. However, Dutch GPs stated it can result in these diagnostic tools are mostly used to take away any an increase in patient anxiety, leading to more uncer- doubt, experienced by the GP, and to reassure the patient. tainty and consultation of a GP. GPs regard personal judgment, not advanced diagnostic tools, as the main instrument to rely on. “Of course raising public awareness is helpful, but it can also cause more unnecessary consultations. Not “Especially because you have to assess the value of an everyone is good at assessing their own situation. And ECG. I mean that an ECG can be negative despite the people are worried when they feel something.” [NL fact that the clinical presentation is very suspicious. GP 12] Then you have to follow your clinical judgment. The technicalities can be an affirmation of your clinical Especially in out-of-hours general practice facilities in assessment but not vice versa.” [BE GP8] the Netherlands, new triage guidelines with a low thresh- old for directly sending out an ambulance in case of chest “It also helps to reassure people that are not expected pain, are causing Dutch GPs to encounter less chest pain to have a serious condition, then you’ll have an patients. Some Flemish GPs stated that recently more pa- additional confirmatory tool [ECG].” [NL GP 12]. tients go directly to the emergency room, especially in urban areas with a high number of immigrants. When a patient is suspected of ACS, GPs immediately refer them to the emergency department, transported by “Outside office hours people often call, saying: “I ambulance with the highest level of urgency. experience an acute severe pressure on my chest”, and according to the current guidelines, the ambulance “But when someone has acute chest pain suspected of will leave for this patient. In such case we don’t assess ACS, that goes with getting picked up by an the patient ourselves.” [NL GP 8] ambulance with the highest urgency.” [NL GP 8]. “We have a varied patient population here. We are on Some GPs considered it acceptable for a patient to the verge of a rural area where most people still leave for the hospital on their own, if the patient is in a Biesemans et al. BMC Family Practice (2018) 19:80 Page 5 of 9 stable condition. However, they should never drive “But my rule is: when I’m uncertain, I always refer the themselves. patient.” [NL GP 10] “Or it is a semi-acute problem and the person can go In less urgent cases some GPs try to perform most to the hospital by their own means of transportation, diagnostics themselves, start a test treatment, or opt for transported by someone else. They shouldn’t drive the approach of watchful waiting, to make a more tar- themselves.” [NL GP 2] geted referral. Before the ambulance arrives, some GPs administer “Yes, I try to rule out some things myself, those things medication and accomplish intravenous access. However, a that are really easy to rule out. (…) And subsequently, few Flemish GPs felt insecure about their knowledge on because of these possibilities, you refer less often.” acute interventions and their necessity in urgent situations. [NL GP 10] “Imagine if you had to suddenly give an injection To diminish uncertainty, GPs stated they could consult urgently: (...) If you haven’t done any of that in twenty colleagues or a cardiologist. However, not all GPs feel years, or haven’t received any information about it the need to do so. Mainly Flemish GPs stated they rarely anymore, you won’t start doing it again that easily, ask for advice on managing chest pain patients. right?” [BE GP10] “I think that we are in a luxury position because we When patients call their GP because of chest pain and work here with three GPs in a group. There is always their situation seems to be unstable, it depends on the someone you can immediately ask for a second amount of time available, whether the GP heads to the pa- opinion. That helps a lot. A short discussion is often tient himself, sends an ambulance directly, or does both. enough to be able to make a decision.” [BE GP5] “Unless I have to drive for fifteen minutes, some of our Sometimes, uncertainty remains after a consultation patients live quite far off, and I am really busy with with a chest pain patient. To reduce this uncertainty, other obligations. But in principle I do both [send an some GPs tend to refer more patients. ambulance and leave for the patient].” [NL GP 2] “Yes, if you have a feeling that you’ve made a mistake In non-urgent cases patients are referred to the hos- somewhere or that you’ve misjudged something it pital cardiology department for a consultation on a fol- certainly keeps…lingering in your head for a while, lowing day. keeps bothering you for a while.” [BE GP14] To GPs, the greatest difficulties in the assessment of chest pain are atypical symptoms, expressed – according Afterwards, some GPs like to debrief cases they were to Dutch GPs – mainly by women. uncertain about, both on medical and personal aspects, either through the cardiologist’s letters or through dis- “Because a woman often has atypical complaints cussion with colleagues. However, some Flemish GPs regarding cardiovascular conditions. You have to be find it difficult to find a safe environment to talk about more careful, which means you maybe have to look a their uncertainty. little closer.” [NL GP 7] “It helps me that I can debrief about it … eh … in a Some GPs feel the need to refer anxious patients, for safe environment. I think that that is one of the most their own and the patient’s peace of mind. important things a GP – and actually any doctor – can attain: safe situations. I’ve been working now for “I think when people keep consulting you with a certain twenty years and I have finally found safety. (…)I complaint, not just chest pain, even if they have already think that that’s important for every doctor, that he consulted you about this complaint earlier, that’san has the opportunity to talk about his uncertainties indication to refer the patient anyway.” [NL GP 2] with his peers.” [BE GP1] In urgent cases, most GPs feel no insecurity in choos- Nonetheless, all GPs believed that insecurity and mis- ing to refer a patient or not. However, when GPs experi- takes are part of their profession and that GPs must ence uncertainty, it is mainly due to doubt as to which learn to handle these situations. Most GPs believed they condition is causing the chest pain, sometimes leading became more confident in assessing chest pain during to more referrals. their career, due to experience and development of their Biesemans et al. BMC Family Practice (2018) 19:80 Page 6 of 9 gut feeling, causing them to refer less patients unneces- situation is different, the insight is different, the sarily. Still, GPs stated they refer quite a large part of patient is different and so on. And then maybe the chest pain patients because they do not want to risk decision would be different. But they can never judge missing ACS. Looking back after obtaining the final you for that!” [BE GP 1] diagnosis, some of these referrals were unnecessary. However, GPs believed this is due to a lack of diagnostic tools to initially rule out ACS. Critical incidents of miss- Thoughts, demands, and doubts concerning new ing ACS cause GPs to be more cautious, either tempor- diagnostic tools (objective 3) arily or permanently. GPs judge their referral decisions Most GPs stated they are satisfied with the current diag- as right or wrong in the light of a final diagnosis. This is nostic options for chest pain patients in general practice remarkable, since a referral decision based on consider- and some believe that clinical assessment will remain ing a severe disease can essentially not be wrong. the most important tool in assessing chest pain patients. Others do believe an additional diagnostic tool such as a “I think the experience and the development of the biomarker PoCT would be useful. Yet, usability strongly gut feeling plays a role in becoming more confident. depends on indications and diagnostic accuracy. A few So, I think that I was more insecure 15 years ago, and Dutch GPs suggested to combine such test with a clin- because of that I may have referred more patients ical decision rule. In general, new diagnostic tools are wrongly.” [NL GP 2] considered to be of a certain degree of added value, with a remaining central role for clinical judgment by the GP. “It is like that, when you get a claim or you think: “Oops, did I miss that?” then you will pay more “Look, if you just… Independently of what it says, and attention to those complaints for a period of time. I think the patient’s situation is not looking good Absolutely.” [NL GP 5] based on the clinical assessment, then I’ll refer him anyway. Then I don’t let it depend on a biomarker.” “Sometimes you have to make a risk assessment. [NL GP 12] Sometimes you are right and sometimes you are wrong. But there’s no dishonour in that. I would “It [PoCT] might contribute something in case of rather refer one patient too many than one too few. doubt. Then of course it also depends on the Because then you are going to have to come up with a sensitivity and the cost price. You have to be quite really good explanation.” [BE GP3] sure when you use such a thing and it comes out positive, that you won’t make big effort which in the Referrals of patients that eventually appear to have no end turns out to be futile.” [BE GP8] severe disease can be unfavourable, leading to high health care costs, an overload of the hospital staff and a “If a clinical decision rule will be designed (...) those stressful experience for patients. However, some GPs are really helpful. You count the points and then you never let their referral decision depend on such possible get yes, no, or an intermediate. Yes, if you add a thresholds. Others stated they try to prevent medicalisa- troponin test to that (...) then I think it will contribute tion and somatisation in low-risk patients. GPs some- of the quality of health care.” [NL GP 8] times get criticised on their referral decisions by hospital physicians. Most GPs claim not to be affected by this criticism, however, their language to express their feeling Discussion of making autonomous referral decisions is rather expli- Summary of main findings cit. Thus, GPs seem to define their position in a difficult First, when suspecting an ACS, GPs base their suspicion field where colleagues and patients might judge the GP’s mainly on history taking and gut feeling. Second, recent decisions. findings in literature are endorsed by the interviewed GPs: chest pain is still a common reason for consulting “I have assessed the patient, so I have to take a GP, the relative number of ACS patients among chest responsibility and I have to make the decision on my pain patients seems decreasing, whereas the presentation own.” [NL GP 1] of atypical complaints increases, leading to more uncer- tainty. Third, GPs compensate for the experienced feel- “That is your autonomous decision. He wasn’t there ing of uncertainty by referring patients, performing at the moment you called. And if you say in that additional tests or discussing cases with colleagues. Be- moment ‘I want an emergency doctor here’, then it sides, GPs regard uncertainty as a substantial part of has to be there, end of story! Ten minutes later, the their profession and they feel more certainty when Biesemans et al. BMC Family Practice (2018) 19:80 Page 7 of 9 working experience increases. Still, some GPs use expli- strategies. Additionally, GPs find that there are more cit language to express their certainty, possibly reflecting atypical presentations of chest pain, due to the growing an ongoing struggle to keep patients and colleagues in awareness of the possible causes of chest pain in the secondary care satisfied. Overall, GPs feel relatively com- general population. This causes chest pain patients to fortable with a certain degree of over-referral of chest worry and consult their GP more often. Dutch GPs state pain patients, as over-referral is regarded as a safe strat- that the prevalence of atypical chest pain in women has egy in dealing with a potentially life threatening condi- increased over the years, possibly due to the growing tion. An ongoing and substantial role for clinical awareness on this subject, and find the management of judgment by the GP is expected. Fourth, new diagnostic these patients challenging. Women indeed present with tools in general practice are anticipated with cautious- atypical chest pain more often than men, but more ness. Proper clinical embedding of such tools is obliga- research on the possibly different pathophysiology in tory according to the interviewed GPs. women and men is needed, in order to reveal the rele- vance of the differences in presentation [25]. Both Dutch Strenghts and limitations of the study and Flemish GPs reported that, in recent years, more Before interviewing the GPs, an extensive tryout of the patients go directly to the emergency room. interview with an experienced GP, observed by another GPs’ judgment of chest pain is based mainly on his- experienced GP, was carried out. Two pilot interviews tory, physical examination and gut feeling. Indeed, it is were performed. All Flemish interviews were carried out known that GPs use additional tools for assessment, by LB, a GP in training. Her own experience from work- such as background knowledge about patients and gut ing in general practice might have had an impact on the feeling [15, 33]. Most GPs question the value and applic- interviews. There might have been bias due to her own ability of currently available diagnostic tools such as opinion on subjects that were discussed. On the other ECG and troponin in the assessment of chest pain. How- hand, her own learning process as a GP might have lead ever, some GPs do use them to take away doubt or to to a curious attitude. The Dutch interviews were carried reassure the patient. When there is a strong suspicion of out by LC and BH, both master’s students in medicine. ACS, GPs immediately refer the patient to the emer- They had no experience in managing chest pain patients gency department. Although most GPs agreed that themselves, possibly leading to a certain degree of transportation by ambulance with the highest level of ur- open-mindedness although the lack of experience could gency is appropriate, some GPs send stable patients to have prevented them from thinking of all possible the hospital by their own means of transport, which is in-depth questions. debatable [34]. Before the ambulance arrives, GPs some- The population of interviewed GPs contained a good times administer medication and accomplish intravenous variety in area, type of practice and age (Table 1). They access. However, several Flemish GPs are reluctant to do might represent a selection of GPs more than averagely this, doubting their ability to perform these interventions. interested in chest pain, although we did not find any Studies on this subject are scarce. A cross-sectional study evidence for such selection bias. Moreover, a selection of from 2008 showed that a training program for GPs on in- interested GPs would lead to an underestimation of terventions for ACS could improve the pre-hospitalization experienced uncertainty, rather than an overestimation. care of these patients [35]. Our study population consisted of more men (n = 18) GPs sometimes experience uncertainty in the manage- than women (n = 9). However, differences of the answers ment of chest pain patients, during or after the consult- between sexes or years of experience as a GP were not ation. GPs tend to reduce this uncertainty by easily observed. All participating GPs seemed motivated to referring patients or performing additional tests. Some respond extensively to our questions. Theoretical data GPs consult their colleagues or a cardiologist to dimin- saturation was reached in the Flemish and Dutch inter- ish uncertainty, though mainly Flemish GPs rarely ask views separately. for advice on managing chest pain. When uncertainty persists after the consultation, most GPs seek confirm- Further findings and comparison to existing literature ation either through the cardiologist’s letters or through The incidence of chest pain in general practice has not discussion with colleagues. GPs overall become more changed remarkably. However, most GPs do experience confident in assessing and managing chest pain patients a change in the clinical spectrum of chest pain, encoun- during their career. tering less cases of ACS, and in its presentation. These GPs mainly feel comfortable with their diagnostic findings are in line with various epidemiological studies, assessment, management and possible over-referral of although data of these studies were partially obtained in chest pain patients, stating that sometimes referral is a hospital setting [26, 27]. The GPs attribute these necessary to get confirmation of the diagnosis. For most changes primarily to better prevention and treatment GPs the unfavourable consequences of ‘unnecessary’ Biesemans et al. BMC Family Practice (2018) 19:80 Page 8 of 9 referrals and criticism by secondary care physicians are Funding The research project on chest pain in general practice of RW, FB, GD and JG not influencing their decisions. Several studies indeed in- is funded by means of an unrestricted grant from FABPulous BV, the dicate that GPs’ clinical judgment is quite accurate and company that develops point-of-care H-FABP-tests. Part of this grant was that they succeed in managing chest pain patients well provided by the Horizon 2020 SME Instrument (RapidEx666666). FABPulous BV agreed not to interfere with data collection, data management and ana- [1, 13, 36]. However, the explicit language used when de- lysis of data. Publication of possibly unfavorable outcomes of our study was scribing their feeling of certainty suggests that GPs are guaranteed. The authors alone are responsible for the content and writing of aware of underlying phenomena. These phenomena the paper. might be reflections of their strong feeling of responsi- Availability of data and materials bility when dealing with possibly life threatening disease The datasets used and analysed during the current study are available from and / or might be a consequence of the feeling of being the corresponding author on reasonable request. judged by patients or colleagues for correctly referring. Authors’ contributions Though most GPs agree that clinical assessment will LB, LC and BH performed the interviews. LB, LC, BH and RW analysed and remain the most important tool in diagnosing chest pain interpreted all data. All authors contributed to the study protocol and read patients, some GPs think that reliable new diagnostic and approved the final manuscript. tools (such as PoCTs) could be a useful addition to im- Authors’ information prove diagnostic accuracy. The general attitude towards LB is general practitioner in Bonheiden, Belgium. LC is a graduating medical such tools seemed more conservative than in recent student at Maastricht University, the Netherlands. RW is general practitioner questionnaire based studies [30, 37]. GPs pointed out in Maastricht, the Netherlands. He is specialised in cardiovascular primary care medicine and is a PhD-candidate at Maastricht University. BH is a gradu- that such tools should be reliably embedded in clinical ating medical student at Maastricht University, the Netherlands. WR is gen- care and is regarded as an additional tool rather than an eral practitioner in Sint-Jans-Molenbeek, Belgium, and researcher at the alternative one making clinical judgments unneeded in Department of General Practice of the Catholic University Leuven, Belgium. FB is general practitioner in Maasmechelen, Belgium, and is emeritus profes- the future. Moreover, dilemmas in assessing chest pain sor at the Department of General Practice of the Catholic University Leuven, patients are thought to partially persist, regardless of fu- Belgium and of Maastricht University, the Netherlands. JG is professor of ture developments. Metabolic Aspects of Cardiovascular Diseases working at the Genetics & Cell Biology Department of Maastricht University, the Netherlands. GJD is general practitioner in Helmond, the Netherlands, and is professor of Family Medi- Conclusions cine at the Family Medicine Department of Maastricht University, the Netherlands. GPs feel that the incidence of chest pain in general Ethics approval and consent to participate practice is not decreasing. However, the number of The study was approved by the Medical Ethical Committees of the University patients having an acute coronary syndrome among of Leuven and of Maastricht University. All participants provided written consent to participate and additional verbal consent was given and patients presenting with chest pain is decreasing, recorded at the start of each interview. whereas the presentation of atypical complaints increases, together leading to more uncertainty. Yet, Competing interests uncertainty is regarded as a substantial element of JG is chief scientific officer (CSO) at FABPulous BV. The remaining authors report no conflicts of interest. their profession. GPs feel relatively comfortable with referring a considerable number of chest pain patients without Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in ACS, as over-referral is safe. published maps and institutional affiliations. New diagnostic tools are awaited with cautiousness: GPs rely on their own judgment, and desire new Author details Department of Family Medicine, Catholic University Leuven, Leuven, diagnostic tools only when these tools are of clear Belgium. Department of Family Medicine, Maastricht University, P. added value. Debyeplein 1, (PO box 616), Maastricht 6200, MD, the Netherlands. Department of Genetics & Cell Biology, Maastricht University, Maastricht, the Netherlands. Additional file Received: 15 January 2018 Accepted: 21 May 2018 Additional file 1: Semi-structured interview. (DOCX 27 kb) References Abbreviations 1. Hoorweg BB, Willemsen RT, Cleef LE, Boogaerts T, Buninx F, Glatz JF, et al. ACS: Acute Coronary Syndrome; CDR: Clinical decision rule; GERD: Gastro- Frequency of chest pain in primary care, diagnostic tests performed and esophageal reflux disease; GP: General practitioner; PoCT: Point of care test final diagnoses. Heart. 2017;103:1727–32. 2. McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Acknowledgements Am Fam Physician. 2013;87:177–82. We sincerely thank all GPs who shared their valuable insights, thoughts 3. Haasenritter J, Biroga T, Keunecke C, Becker A, Donner-Banzhoff N, and doubts concerning chest pain patients with us, in a talkative and Dornieden K, et al. Causes of chest pain in primary care–a systematic review open-hearted manner. and meta-analysis. Croat Med J. 2015;56:422–30. Biesemans et al. BMC Family Practice (2018) 19:80 Page 9 of 9 4. Buntinx F, Knockaert D, Bruyninckx R, Deblaey N, Aerts M, Knottnerus JA, 25. Bosner S, Haasenritter J, Hani MA, Keller H, Sönnichsen AC, Karatolios K, et al. 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Current and future use of point-of-care tests in primary care: an ESC guidelines for the management of acute coronary syndromes in international survey in Australia, Belgium, the Netherlands, the UK and patients presenting without persistent ST-segment elevation: task force for the USA. BMJ Open. 2014;4:e005611. https://doi.org/10.1136/bmjopen- the Management of Acute Coronary Syndromes in patients presenting 2014-005611. without persistent ST-segment elevation of the European Society of 31. Ayerbe L, Gonzalez E, Gallo V, Coleman CL, Wragg A, Robson J. Clinical Cardiology (ESC). Eur Heart J. 2016;37:267–315. assessment of patients with chest pain; a systematic review of 10. Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J. The health predictive tools. BMC Cardiovasc Disord. 2016;16:18. https://doi.org/10. care burden of acute chest pain. Heart. 2005;91:229–30. 1186/s12872-016-0196-4. 11. Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG. “Could this 32. 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An observational study of variation in GPs’ out-of-hours emergency referrals. Br J Gen Pract. 2007;57:152–4. 23. Canto JG, Goldberg RJ, Hand MM, Bonow RO, Sopko G, Pepine CJ, et al. Symptom presentation of women with acute coronary syndromes: myth vs reality. Arch Intern Med. 2007;167:2405–13. 24. Dey S, Flather MD, Devlin G, Brieger D, Gurfinkel EP, Steg PG, et al. Sex- related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the global registry of acute coronary events. Heart. 2009;95:20–6. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

Managing chest pain patients in general practice: an interview-based study

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Abstract

Background: Assessment of chest pain in general practice is challenging. General practitioners (GPs) often feel uncertainty when dealing with chest pain. The role of new diagnostic tools is yet unclear. Therefore, we aimed to learn: (1) whether or not GPs experience a change in incidence and presentation of chest pain, (2) how GPs deal with uncertainty, and (3) which thoughts, demands and doubts concerning new diagnostic tools occur. Methods: Semi-structured, face to face interview based study, aiming at six main subjects: experienced changes in prevalence of chest pain, the management of chest pain patients, dealing with uncertainty, the GPs’ approach in referring chest pain patients, GPs’ attitude towards ‘unnecessary’ referrals, and the GPs’ suggestions for improving the management of chest pain patients. Results: 145 GPs in Belgium and the Netherlands were invited to participate, 27 (15 Flemish and 12 Dutch) GPs were interviewed. Data saturation was reached. The number of patients having an acute coronary syndrome among chest pain patients is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. GPs rely on their own judgment above all, and desire new diagnostic tools only when these tools are of proven added value. Conclusion: The incidence of chest pain in general practice is not decreasing according to the GPs. However, the presentation of chest pain is changing. GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe. Uncertainty is regarded as a substantial element of their profession. New diagnostic tools are awaited with cautiousness. Keywords: General practice, Cardiovascular disorders, Diagnostic tests, Urgent care, Risk assessment Background and less severe causes of chest pain, based on clinical find- Chest pain in general practice ings or electrocardiography, is difficult [5–8]. In general practice, chest pain as a reason for encounter is common (prevalence 1–3%) and differential diagnosis The challenge of (not) referring patients with chest pain is broad [1, 2]. Yet, in only a minority, an acute life threat- Most guidelines clearly state that general practitioners ening disease is concerned. Severe diseases as acute cor- (GPs) should refer every patient suspected of an ACS to onary syndrome (ACS), pulmonary embolism or thoracic secondary care facilities as soon as possible, or GPs aortal dissection are outnumbered by non-urgent causes should even be bypassed to prevent loss of time and, as gastro-esophageal reflux disease (GERD) or thoracic consequently, myocardial cell necrosis [9]. However, for wall pain [1, 3, 4]. However, discriminating between ACS every chest pain patient with a life threatening disease as ACS, a GP encounters 11 patients with chest pain of a * Correspondence: robert.willemsen@maastrichtuniversity.nl Leen Biesemans, Lotte E. Cleef and Robert T. A. Willemsen contributed non severe cause [1]. Therefore, clinical judgement and equally to this work. triage by GPs remains inevitable to prevent unnecessary Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO referrals and to keep the burden on secondary care facilities box 616), Maastricht 6200, MD, the Netherlands Full list of author information is available at the end of the article acceptable [3, 10]. To reach this goal, GPs compromise © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Biesemans et al. BMC Family Practice (2018) 19:80 Page 2 of 9 between adequate detection of severe disease on the one especially in the field of patients presenting with chest hand and reassurement in cases of worried patients with no pain [30]. However, a CDR safely reducing referrals is or mild underlying disease on the other hand [6, 11, 12]. lacking [31]. Over time, GPs seem to have found an optimum. They refer only a minority of chest pain patients, thereby ad- Objectives equately maintaining their gatekeeping role. Still, a consid- Studies on GPs’ contemporary perceptions, attitudes and erable number of patients with chest pain (approximately experiences in dealing with chest pain patients regarding 20–40%) are referred for safe exclusion of ACS, whereas uncertainty and developments in presentation, incidence only one out of five of these referred patients suffer from and diagnostic tools as described above are mainly dealing severe disease [1, 13, 14]. Besides classical clinical findings, with specific diseases, are focussing on out of office hours GPs use gut feeling and background knowledge of their pa- working situations or are lacking [16, 17, 32]. Therefore, tients to make these challenging referral decisions [15]. in our study, we aimed to explore the following topics: Uncertainty when dealing with chest pain (1) Do GPs experience a changing incidence and Notwithstanding this strategy to work with low thresh- presentation of chest pain and / or ACS in daily olds for referral to maintain the number of missed cases practice, and if so, what changes do GPs observe? of ACS low, uncertainty among GPs has been a part of (2) Which considerations are important to GPs and dealing with chest pain in general practice for decades how do they deal with uncertainty (regarding [16–18]. GPs regard guidelines as only partially solving referrals of patients without a life threatening their dilemmas in assessing chest pain patients and as disease as well as missed cases of severe disease) in suboptimally answering their questions whether or not the management of chest pain patients? to refer these patients [16]. As a possible consequence, (3) Which thoughts, demands and doubts concerning guidelines do not integrally lead to behavioural change new diagnostic tools can be extracted from GPs’ [19]. Besides, referring patients without consultation – reflections on managing patients with chest pain? for example based on a typical pattern presented in a (This final question was addressed only in the phone call, as is advertised in cases of suspected stroke Dutch interviews, since most Flemish GPs have no – is impracticable in cases of chest pain due to the broad experience with such tools). differential diagnosis [20]. Cautious GPs that are anxious about the consequences of missing severe disease refer Methods more often to secondary care facilities, especially when Inclusion working in out of office hours services [21, 22]. Espe- 145 GPs were selected from a list of GPs who had indi- cially during consultations during out of office hours, cated earlier they were interested in participating in maintaining a threshold for referral is challenging [17]. scientific studies. We invited 15 Flemish GPs by phone and 30 per e-mail. 100 Dutch GPs were invited per Developments in the field of chest pain in general e-mail and were phoned shortly afterwards to inquire practice possible participation. We included general practitioners Several developments in the field of chest pain in general willing to participate, with at least 5 years of working practice have been described. First, an altering presenta- experience. No further selection criteria were used. tion of ACS in general practice has been reported, whether or not due to sex differences in presentation Interview [5, 23–25]. Second, incidence of ACS among chest The semi-structured face-to-face interview, composed pain patients in general practice seems to be declining by the Flemish researchers, consisted of five main sub- over the years (from approximately 20% to less than 10%), jects to answer the objectives of the study: (1) recently mortality has decreased strongly, and prognosis has im- experienced changes in the prevalence of chest pain and proved [1, 26, 27]. Besides absolute data on this topic ad- ACS, (2) management of chest pain patients in daily dressed in quantitative studies, a GP’s perception of a practice, (3) dealing with uncertainty, (4) the GPs’ approach possible changing incidence of ACS is important, since a in referring chest pain patients, and (5) their attitude to- GP’s estimation of the probability of an ACS when asses- wards - in the light of the final diagnosis - ‘unnecessary’ re- sing patients presenting with chest pain (the ‘pre-test ferrals. The second subject (2) was approached by letting probability’) is influenced by this perception [28, 29]. the GPs imagine a chest pain patient and thereby reflect on Third, several diagnostic studies have recently evaluated their diagnostic steps and decision to refer. An additional the role of new diagnostic tools – e.g. clinical decision subject was added in the Dutch interview: (6) the GP’sown rules (CDRs) and point-of-care tests (PoCTs) – in man- suggestions for improving the management of chest pain aging chest pain patients. GPs in Europe desire a PoCT patients in general practice. The interview protocol was Biesemans et al. BMC Family Practice (2018) 19:80 Page 3 of 9 piloted with a Flemish and a Dutch GP who both had over Ethics 25 years of working experience. Flaws were discussed by All participants were informed about the aims of the the researchers and two GPs, which resulted in an adapted study and the recording of the interviews. The study was version of the interview. The pilot interviews were not in- approved by the Medical Ethical Committees of the Uni- cluded in the final research sample. The main questions, versity of Leuven and of Maastricht University. used as starting points of different phases of the interview are given in Additional file 1. Additional questions were not Results predefined, further answers and themes were initiated by 145 (45 Flemish, 100 Dutch) GPs were invited to partici- the GPs themselves. The interviews took place at the GPs’ pate, 27 GPs (15 Flemish and 12 Dutch) were inter- practices, incidentally in a GP’sprivate home. viewed. The main reason for declining our invitation was a lack of time. GP characteristics are presented in Table 1. During the interviews, all GPs commented ex- Data collection tensively on the questions concerning this study’s main Data were collected through face-to-face interviews. three objectives. All interviews lasted 45 to 60 min, inci- Flemish interviews were carried out by LB, as part of her dentally an interview lasted 75 min. research thesis completing her GP education, between June and October, 2015. Dutch interviews were carried Incidence and presentation of chest pain in general out by LC and BH, both fulfilling their research intern- practice (objective 1) ships during the master phase of their medical school, Most GPs stated that they are confronted with chest between April and June, 2016. All interviews were pain at least once every week. Chest pain can have a audio-recorded and transcribed verbatim. Data were col- wide variety of causes, of which the majority is not of lected until saturation was achieved. Saturation was de- cardiac origin. fined as the identification of no new nodes in the last two interviews in the Flemish, or the Dutch part of the “Hm, I think we are confronted with this study, respectively. complaint weekly, maybe even multiple times a week.” [NLGP12] Data analysis Thematic analysis was used to bring forth answers to Table 1 Characteristics (gender, age, years of experience, type the main objectives of this study. All Flemish interview and area of practice) of the participating GPs transcripts were analysed independently by two re- Dutch Flemish Total searchers in a process of inductive line-by-line coding. Gender Male 8 10 18 LB coded all transcripts, and four GP residents and one Female 4 5 9 anesthesiology resident coded three transcripts each. Age groups 35–39 1 2 3 Afterwards, differences were discussed and further ana- lysis was assisted by FB and WR. Thereafter, the initial 40–44 4 0 4 codebook was established, which was adjusted after 45–49 0 4 4 every four interviews. In a second step the codes were 50–54 1 2 3 refined, resulting in the development of descriptive 55–59 5 2 7 themes. Finally, a thematic analysis was performed by all 59–65 1 4 5 researchers to generate new analytical themes. >65 0 1 1 Each Dutch interview was analysed and coded inde- pendently using the Flemish codebook by LC and BH. Years of experience 20.6 (2.5–36) 26.7 (10–40) 24.0 (2.5–40) Conflicts were solved by discussion. During the analysis Type of practice Single 4 4 8 of subsequent interviews, the initial code list was further Duo 5 4 9 refined by adding new codes under the pre-existing Group 3 7 10 themes, when confronted with relevant data that could Area of practice Urban 8 6 14 not be linked to an existing code. Finally, a framework Rural 4 9 13 analysis was performed by LC, BH, and RW to generate new hypotheses. Ultimately, Flemish and Dutch results Through purposive sampling we aimed to attain a heterogeneous group, including both female and male GPs, GPs working in both rural and urban were independently analysed and discussed by LB, LC regions and in single, duo and group practices. One participating GP had only and RW to uncover similarities and differences in out- 2,5 years of experience. Yet the data derived from this interview were maintained, since these were in line with the data from the more experienced comes. Subsequently, these findings were documented GPs. Single, duo, group practices refer to GP practices managed by when applicable in the results section of this paper. respectively one, two and more GPs. Abbreviations: GP general practitioner, N NVivo 11 pro software was used to facilitate coding. number. Mean followed by the range in brackets Biesemans et al. BMC Family Practice (2018) 19:80 Page 4 of 9 “Yes, the lion’s share here, of people presenting with obediently go to the GP. On the other hand, in the chest pain, is not of cardiac origin.” [NL GP 8] city of Mechelen e.g., the citizens – and certainly the immigrants – go to the emergency department much Although some Dutch GPs experienced an evident easier and will thus pass us by.” [BE GP6] increase in the prevalence of chest pain in their practice, the majority of GPs did not experience a change in fre- quency over time. However, most GPs experienced a Assessment of chest pain and dealing with uncertainty change in the clinical spectrum of chest pain. GPs claimed (objective 2) to encounter less cases of ACS, due to improved cardio- When confronted with a chest pain patient, GPs quickly vascular risk management in general practice, and more attempt to distinguish between acute and non-acute path- atypical thoracic complaints, due to a growing awareness ology. The most important tools in assessing chest pain on chest pain in the general population. The anxiety ac- are history taking, clinical evaluation and gut feeling. The companying this awareness, combined with the continu- language used by GPs suggests a feeling of responsibility. ously available health care in large out-of-hours general practice facilities, lower the threshold to consult a GP. “Yes, you first try to determine in which framework the pain fits. (…) Are the lungs causing the problems, or is “Then I think it is more or less the same … if you don’t it the heart or is it something less serious? So that’s only count cardiac but also other types of chest pain what you try to assess first and foremost.” [BE GP10] like respiratory infections or indeed psychosomatic symptoms. Then I think it [the frequency of chest pain] “But I taught myself, if I have a certain gut feeling that is comparable to before.” [BE GP 4] something isn’t right, yes, then I just refer them. I’m not going to take the risk behind the patient’s back.” “I think that the frequency with which we see a grave [NL GP 11] acute infarction nowadays is a lot lower than it was twenty years ago.” [BE GP 7] Most GPs questioned the value of diagnostic tools such as ECG or troponin in ruling out ACS at first assessment. Most GPs believed raising awareness in the general However, a few GPs felt confident enough to not refer a population on the possible consequences of chest pain is patient based on a negative ECG. In non-acute situations, important. However, Dutch GPs stated it can result in these diagnostic tools are mostly used to take away any an increase in patient anxiety, leading to more uncer- doubt, experienced by the GP, and to reassure the patient. tainty and consultation of a GP. GPs regard personal judgment, not advanced diagnostic tools, as the main instrument to rely on. “Of course raising public awareness is helpful, but it can also cause more unnecessary consultations. Not “Especially because you have to assess the value of an everyone is good at assessing their own situation. And ECG. I mean that an ECG can be negative despite the people are worried when they feel something.” [NL fact that the clinical presentation is very suspicious. GP 12] Then you have to follow your clinical judgment. The technicalities can be an affirmation of your clinical Especially in out-of-hours general practice facilities in assessment but not vice versa.” [BE GP8] the Netherlands, new triage guidelines with a low thresh- old for directly sending out an ambulance in case of chest “It also helps to reassure people that are not expected pain, are causing Dutch GPs to encounter less chest pain to have a serious condition, then you’ll have an patients. Some Flemish GPs stated that recently more pa- additional confirmatory tool [ECG].” [NL GP 12]. tients go directly to the emergency room, especially in urban areas with a high number of immigrants. When a patient is suspected of ACS, GPs immediately refer them to the emergency department, transported by “Outside office hours people often call, saying: “I ambulance with the highest level of urgency. experience an acute severe pressure on my chest”, and according to the current guidelines, the ambulance “But when someone has acute chest pain suspected of will leave for this patient. In such case we don’t assess ACS, that goes with getting picked up by an the patient ourselves.” [NL GP 8] ambulance with the highest urgency.” [NL GP 8]. “We have a varied patient population here. We are on Some GPs considered it acceptable for a patient to the verge of a rural area where most people still leave for the hospital on their own, if the patient is in a Biesemans et al. BMC Family Practice (2018) 19:80 Page 5 of 9 stable condition. However, they should never drive “But my rule is: when I’m uncertain, I always refer the themselves. patient.” [NL GP 10] “Or it is a semi-acute problem and the person can go In less urgent cases some GPs try to perform most to the hospital by their own means of transportation, diagnostics themselves, start a test treatment, or opt for transported by someone else. They shouldn’t drive the approach of watchful waiting, to make a more tar- themselves.” [NL GP 2] geted referral. Before the ambulance arrives, some GPs administer “Yes, I try to rule out some things myself, those things medication and accomplish intravenous access. However, a that are really easy to rule out. (…) And subsequently, few Flemish GPs felt insecure about their knowledge on because of these possibilities, you refer less often.” acute interventions and their necessity in urgent situations. [NL GP 10] “Imagine if you had to suddenly give an injection To diminish uncertainty, GPs stated they could consult urgently: (...) If you haven’t done any of that in twenty colleagues or a cardiologist. However, not all GPs feel years, or haven’t received any information about it the need to do so. Mainly Flemish GPs stated they rarely anymore, you won’t start doing it again that easily, ask for advice on managing chest pain patients. right?” [BE GP10] “I think that we are in a luxury position because we When patients call their GP because of chest pain and work here with three GPs in a group. There is always their situation seems to be unstable, it depends on the someone you can immediately ask for a second amount of time available, whether the GP heads to the pa- opinion. That helps a lot. A short discussion is often tient himself, sends an ambulance directly, or does both. enough to be able to make a decision.” [BE GP5] “Unless I have to drive for fifteen minutes, some of our Sometimes, uncertainty remains after a consultation patients live quite far off, and I am really busy with with a chest pain patient. To reduce this uncertainty, other obligations. But in principle I do both [send an some GPs tend to refer more patients. ambulance and leave for the patient].” [NL GP 2] “Yes, if you have a feeling that you’ve made a mistake In non-urgent cases patients are referred to the hos- somewhere or that you’ve misjudged something it pital cardiology department for a consultation on a fol- certainly keeps…lingering in your head for a while, lowing day. keeps bothering you for a while.” [BE GP14] To GPs, the greatest difficulties in the assessment of chest pain are atypical symptoms, expressed – according Afterwards, some GPs like to debrief cases they were to Dutch GPs – mainly by women. uncertain about, both on medical and personal aspects, either through the cardiologist’s letters or through dis- “Because a woman often has atypical complaints cussion with colleagues. However, some Flemish GPs regarding cardiovascular conditions. You have to be find it difficult to find a safe environment to talk about more careful, which means you maybe have to look a their uncertainty. little closer.” [NL GP 7] “It helps me that I can debrief about it … eh … in a Some GPs feel the need to refer anxious patients, for safe environment. I think that that is one of the most their own and the patient’s peace of mind. important things a GP – and actually any doctor – can attain: safe situations. I’ve been working now for “I think when people keep consulting you with a certain twenty years and I have finally found safety. (…)I complaint, not just chest pain, even if they have already think that that’s important for every doctor, that he consulted you about this complaint earlier, that’san has the opportunity to talk about his uncertainties indication to refer the patient anyway.” [NL GP 2] with his peers.” [BE GP1] In urgent cases, most GPs feel no insecurity in choos- Nonetheless, all GPs believed that insecurity and mis- ing to refer a patient or not. However, when GPs experi- takes are part of their profession and that GPs must ence uncertainty, it is mainly due to doubt as to which learn to handle these situations. Most GPs believed they condition is causing the chest pain, sometimes leading became more confident in assessing chest pain during to more referrals. their career, due to experience and development of their Biesemans et al. BMC Family Practice (2018) 19:80 Page 6 of 9 gut feeling, causing them to refer less patients unneces- situation is different, the insight is different, the sarily. Still, GPs stated they refer quite a large part of patient is different and so on. And then maybe the chest pain patients because they do not want to risk decision would be different. But they can never judge missing ACS. Looking back after obtaining the final you for that!” [BE GP 1] diagnosis, some of these referrals were unnecessary. However, GPs believed this is due to a lack of diagnostic tools to initially rule out ACS. Critical incidents of miss- Thoughts, demands, and doubts concerning new ing ACS cause GPs to be more cautious, either tempor- diagnostic tools (objective 3) arily or permanently. GPs judge their referral decisions Most GPs stated they are satisfied with the current diag- as right or wrong in the light of a final diagnosis. This is nostic options for chest pain patients in general practice remarkable, since a referral decision based on consider- and some believe that clinical assessment will remain ing a severe disease can essentially not be wrong. the most important tool in assessing chest pain patients. Others do believe an additional diagnostic tool such as a “I think the experience and the development of the biomarker PoCT would be useful. Yet, usability strongly gut feeling plays a role in becoming more confident. depends on indications and diagnostic accuracy. A few So, I think that I was more insecure 15 years ago, and Dutch GPs suggested to combine such test with a clin- because of that I may have referred more patients ical decision rule. In general, new diagnostic tools are wrongly.” [NL GP 2] considered to be of a certain degree of added value, with a remaining central role for clinical judgment by the GP. “It is like that, when you get a claim or you think: “Oops, did I miss that?” then you will pay more “Look, if you just… Independently of what it says, and attention to those complaints for a period of time. I think the patient’s situation is not looking good Absolutely.” [NL GP 5] based on the clinical assessment, then I’ll refer him anyway. Then I don’t let it depend on a biomarker.” “Sometimes you have to make a risk assessment. [NL GP 12] Sometimes you are right and sometimes you are wrong. But there’s no dishonour in that. I would “It [PoCT] might contribute something in case of rather refer one patient too many than one too few. doubt. Then of course it also depends on the Because then you are going to have to come up with a sensitivity and the cost price. You have to be quite really good explanation.” [BE GP3] sure when you use such a thing and it comes out positive, that you won’t make big effort which in the Referrals of patients that eventually appear to have no end turns out to be futile.” [BE GP8] severe disease can be unfavourable, leading to high health care costs, an overload of the hospital staff and a “If a clinical decision rule will be designed (...) those stressful experience for patients. However, some GPs are really helpful. You count the points and then you never let their referral decision depend on such possible get yes, no, or an intermediate. Yes, if you add a thresholds. Others stated they try to prevent medicalisa- troponin test to that (...) then I think it will contribute tion and somatisation in low-risk patients. GPs some- of the quality of health care.” [NL GP 8] times get criticised on their referral decisions by hospital physicians. Most GPs claim not to be affected by this criticism, however, their language to express their feeling Discussion of making autonomous referral decisions is rather expli- Summary of main findings cit. Thus, GPs seem to define their position in a difficult First, when suspecting an ACS, GPs base their suspicion field where colleagues and patients might judge the GP’s mainly on history taking and gut feeling. Second, recent decisions. findings in literature are endorsed by the interviewed GPs: chest pain is still a common reason for consulting “I have assessed the patient, so I have to take a GP, the relative number of ACS patients among chest responsibility and I have to make the decision on my pain patients seems decreasing, whereas the presentation own.” [NL GP 1] of atypical complaints increases, leading to more uncer- tainty. Third, GPs compensate for the experienced feel- “That is your autonomous decision. He wasn’t there ing of uncertainty by referring patients, performing at the moment you called. And if you say in that additional tests or discussing cases with colleagues. Be- moment ‘I want an emergency doctor here’, then it sides, GPs regard uncertainty as a substantial part of has to be there, end of story! Ten minutes later, the their profession and they feel more certainty when Biesemans et al. BMC Family Practice (2018) 19:80 Page 7 of 9 working experience increases. Still, some GPs use expli- strategies. Additionally, GPs find that there are more cit language to express their certainty, possibly reflecting atypical presentations of chest pain, due to the growing an ongoing struggle to keep patients and colleagues in awareness of the possible causes of chest pain in the secondary care satisfied. Overall, GPs feel relatively com- general population. This causes chest pain patients to fortable with a certain degree of over-referral of chest worry and consult their GP more often. Dutch GPs state pain patients, as over-referral is regarded as a safe strat- that the prevalence of atypical chest pain in women has egy in dealing with a potentially life threatening condi- increased over the years, possibly due to the growing tion. An ongoing and substantial role for clinical awareness on this subject, and find the management of judgment by the GP is expected. Fourth, new diagnostic these patients challenging. Women indeed present with tools in general practice are anticipated with cautious- atypical chest pain more often than men, but more ness. Proper clinical embedding of such tools is obliga- research on the possibly different pathophysiology in tory according to the interviewed GPs. women and men is needed, in order to reveal the rele- vance of the differences in presentation [25]. Both Dutch Strenghts and limitations of the study and Flemish GPs reported that, in recent years, more Before interviewing the GPs, an extensive tryout of the patients go directly to the emergency room. interview with an experienced GP, observed by another GPs’ judgment of chest pain is based mainly on his- experienced GP, was carried out. Two pilot interviews tory, physical examination and gut feeling. Indeed, it is were performed. All Flemish interviews were carried out known that GPs use additional tools for assessment, by LB, a GP in training. Her own experience from work- such as background knowledge about patients and gut ing in general practice might have had an impact on the feeling [15, 33]. Most GPs question the value and applic- interviews. There might have been bias due to her own ability of currently available diagnostic tools such as opinion on subjects that were discussed. On the other ECG and troponin in the assessment of chest pain. How- hand, her own learning process as a GP might have lead ever, some GPs do use them to take away doubt or to to a curious attitude. The Dutch interviews were carried reassure the patient. When there is a strong suspicion of out by LC and BH, both master’s students in medicine. ACS, GPs immediately refer the patient to the emer- They had no experience in managing chest pain patients gency department. Although most GPs agreed that themselves, possibly leading to a certain degree of transportation by ambulance with the highest level of ur- open-mindedness although the lack of experience could gency is appropriate, some GPs send stable patients to have prevented them from thinking of all possible the hospital by their own means of transport, which is in-depth questions. debatable [34]. Before the ambulance arrives, GPs some- The population of interviewed GPs contained a good times administer medication and accomplish intravenous variety in area, type of practice and age (Table 1). They access. However, several Flemish GPs are reluctant to do might represent a selection of GPs more than averagely this, doubting their ability to perform these interventions. interested in chest pain, although we did not find any Studies on this subject are scarce. A cross-sectional study evidence for such selection bias. Moreover, a selection of from 2008 showed that a training program for GPs on in- interested GPs would lead to an underestimation of terventions for ACS could improve the pre-hospitalization experienced uncertainty, rather than an overestimation. care of these patients [35]. Our study population consisted of more men (n = 18) GPs sometimes experience uncertainty in the manage- than women (n = 9). However, differences of the answers ment of chest pain patients, during or after the consult- between sexes or years of experience as a GP were not ation. GPs tend to reduce this uncertainty by easily observed. All participating GPs seemed motivated to referring patients or performing additional tests. Some respond extensively to our questions. Theoretical data GPs consult their colleagues or a cardiologist to dimin- saturation was reached in the Flemish and Dutch inter- ish uncertainty, though mainly Flemish GPs rarely ask views separately. for advice on managing chest pain. When uncertainty persists after the consultation, most GPs seek confirm- Further findings and comparison to existing literature ation either through the cardiologist’s letters or through The incidence of chest pain in general practice has not discussion with colleagues. GPs overall become more changed remarkably. However, most GPs do experience confident in assessing and managing chest pain patients a change in the clinical spectrum of chest pain, encoun- during their career. tering less cases of ACS, and in its presentation. These GPs mainly feel comfortable with their diagnostic findings are in line with various epidemiological studies, assessment, management and possible over-referral of although data of these studies were partially obtained in chest pain patients, stating that sometimes referral is a hospital setting [26, 27]. The GPs attribute these necessary to get confirmation of the diagnosis. For most changes primarily to better prevention and treatment GPs the unfavourable consequences of ‘unnecessary’ Biesemans et al. BMC Family Practice (2018) 19:80 Page 8 of 9 referrals and criticism by secondary care physicians are Funding The research project on chest pain in general practice of RW, FB, GD and JG not influencing their decisions. Several studies indeed in- is funded by means of an unrestricted grant from FABPulous BV, the dicate that GPs’ clinical judgment is quite accurate and company that develops point-of-care H-FABP-tests. Part of this grant was that they succeed in managing chest pain patients well provided by the Horizon 2020 SME Instrument (RapidEx666666). FABPulous BV agreed not to interfere with data collection, data management and ana- [1, 13, 36]. However, the explicit language used when de- lysis of data. Publication of possibly unfavorable outcomes of our study was scribing their feeling of certainty suggests that GPs are guaranteed. The authors alone are responsible for the content and writing of aware of underlying phenomena. These phenomena the paper. might be reflections of their strong feeling of responsi- Availability of data and materials bility when dealing with possibly life threatening disease The datasets used and analysed during the current study are available from and / or might be a consequence of the feeling of being the corresponding author on reasonable request. judged by patients or colleagues for correctly referring. Authors’ contributions Though most GPs agree that clinical assessment will LB, LC and BH performed the interviews. LB, LC, BH and RW analysed and remain the most important tool in diagnosing chest pain interpreted all data. All authors contributed to the study protocol and read patients, some GPs think that reliable new diagnostic and approved the final manuscript. tools (such as PoCTs) could be a useful addition to im- Authors’ information prove diagnostic accuracy. The general attitude towards LB is general practitioner in Bonheiden, Belgium. LC is a graduating medical such tools seemed more conservative than in recent student at Maastricht University, the Netherlands. RW is general practitioner questionnaire based studies [30, 37]. GPs pointed out in Maastricht, the Netherlands. He is specialised in cardiovascular primary care medicine and is a PhD-candidate at Maastricht University. BH is a gradu- that such tools should be reliably embedded in clinical ating medical student at Maastricht University, the Netherlands. WR is gen- care and is regarded as an additional tool rather than an eral practitioner in Sint-Jans-Molenbeek, Belgium, and researcher at the alternative one making clinical judgments unneeded in Department of General Practice of the Catholic University Leuven, Belgium. FB is general practitioner in Maasmechelen, Belgium, and is emeritus profes- the future. Moreover, dilemmas in assessing chest pain sor at the Department of General Practice of the Catholic University Leuven, patients are thought to partially persist, regardless of fu- Belgium and of Maastricht University, the Netherlands. JG is professor of ture developments. Metabolic Aspects of Cardiovascular Diseases working at the Genetics & Cell Biology Department of Maastricht University, the Netherlands. GJD is general practitioner in Helmond, the Netherlands, and is professor of Family Medi- Conclusions cine at the Family Medicine Department of Maastricht University, the Netherlands. GPs feel that the incidence of chest pain in general Ethics approval and consent to participate practice is not decreasing. However, the number of The study was approved by the Medical Ethical Committees of the University patients having an acute coronary syndrome among of Leuven and of Maastricht University. All participants provided written consent to participate and additional verbal consent was given and patients presenting with chest pain is decreasing, recorded at the start of each interview. whereas the presentation of atypical complaints increases, together leading to more uncertainty. Yet, Competing interests uncertainty is regarded as a substantial element of JG is chief scientific officer (CSO) at FABPulous BV. The remaining authors report no conflicts of interest. their profession. GPs feel relatively comfortable with referring a considerable number of chest pain patients without Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in ACS, as over-referral is safe. published maps and institutional affiliations. New diagnostic tools are awaited with cautiousness: GPs rely on their own judgment, and desire new Author details Department of Family Medicine, Catholic University Leuven, Leuven, diagnostic tools only when these tools are of clear Belgium. Department of Family Medicine, Maastricht University, P. added value. Debyeplein 1, (PO box 616), Maastricht 6200, MD, the Netherlands. Department of Genetics & Cell Biology, Maastricht University, Maastricht, the Netherlands. Additional file Received: 15 January 2018 Accepted: 21 May 2018 Additional file 1: Semi-structured interview. (DOCX 27 kb) References Abbreviations 1. Hoorweg BB, Willemsen RT, Cleef LE, Boogaerts T, Buninx F, Glatz JF, et al. 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BMC Family PracticeSpringer Journals

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