Chest Pain: Physician Perceptions and Decisionmaking in a London Emergency Department

Study objective We describe physician perceptions of decisionmaking 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. Conclusion 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 decisionmaking.