Chest pain: physician perceptions and decision-making in a London emergency department.
OBJECTIVE
We describe physician perceptions of decision-making for acute coronary syndromes in the emergency department (ED) and the ways in which patient characteristics influence diagnosis.


METHODS
This is a qualitative analysis of semistructured interview data from physicians practicing at an ethnically diverse and lower-income London ED. All physicians working more than 3 shifts in the department during a 1-month period were approached for interview.


RESULTS
Four themes emerged from the interviews: (1) physicians emphasized the medical history when diagnosing acute coronary syndrome; (2) physicians reported communication barriers as an impediment to diagnosis; (3) physicians cited both epidemiologic data and cultural beliefs when explaining presentation differences between patient groups; (4) physicians interpreted patient complaints by comparing their clinical impressions to a "classic" or "textbook" norm.


CONCLUSIONS
In most cases, physicians relied on the clinical history when making decisions for patients with suspected acute coronary syndromes. In reaching judgments, physicians elicited features of the presentation they thought were salient, interpreted those features in light of epidemiologic knowledge and cultural beliefs, and compared their overall impression of the patient to a "classic" or "textbook" norm. At each step, physicians' perceptions about patients influenced the data gathered and the interpretation of that data. In addition, the expected features of acute coronary syndrome were thought to differ for some patient groups. These results highlight the need for further research into the role of provider beliefs in medical decision-making.
Farmer
Steven A
SA
Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA. Steven.Farmer@aya.yale.edu
Higginson
Irene J
IJ
D000367:Age Factors; D001291:Attitude of Health Personnel; D002637:Chest Pain / Q000208:ethnology; D003144:Communication Barriers; D003657:Decision Making; D004636:Emergency Service, Hospital; D006785:Hospitals, University; D006801:Humans; D007407:Interviews as Topic; D008131:London; D008487:Medical History Taking; D008505:Medical Staff, Hospital / Q000523:psychology; D009203:Myocardial Infarction / Q000175:diagnosis; D010817:Physician-Patient Relations; D010820:Physicians / Q000523:psychology