Physician Clinical Gestalt Formation in Acute Coronary Syndrome: A Qualitative Study

Bosch, P. (Paul) (2016) Physician Clinical Gestalt Formation in Acute Coronary Syndrome: A Qualitative Study. thesis, Medicine.

Text BoschP.pdf Restricted to Registered users only Download (681kB)

Abstract

Introduction: Patients presenting with acute chest pain form a large portion of the cases seen in the emergency department. Quick recognition of chest pain due to Acute Coronary Syndrome (ACS) is of vital importance. Diagnostics in patients presenting without obvious signs of cardiac ischemia is challenging, and is mainly based on the information from the clinical history and the current presentation. This information can be assessed objectively by using risk scores like the HEART score. However, physicians can also form an unstructured, more subjective estimation on the likelihood of ACS, called the physicians ‘clinical gestalt’. These strategies have similar validity, however, the exact information used in forming the clinical gestalt is unclear. The current study aims to identify the factors contributing to the formation of the physician’s clinical gestalt in cases of suspected ACS without obvious signs of cardiac ischemia. Methods: Ten cardiology residents working in the emergency department of the University Medical Center Groningen (UMCG) were interviewed about their diagnostics process. Face-to-face interviews were conducted, then transcribed and coded using qualitative analysis software. Results: The residents based their assessment of the patient on experience, guidelines, and training. The most important factors contributing to the formation of the physician’s clinical gestalt were the pain presentation, the patient’s clinical history, risk factors for cardiovascular disease, and unquantifiable factors related to the patients appearance. Some residents used risk scores to objectively assess the information from the clinical history, though none of the risk scores used were designed for diagnostic purposes. Discussion: Not all pain characteristics used by the residents in this study are sufficiently validated to be used as diagnostic for ACS. However, pain radiating to one or both arms that is provoked by exercise is validated as typical for ischemic cardiac chest pain, so these characteristics should be used when suspecting ACS. Residents in this study also value certain subjective factors related to a patient’s presentation, like ‘appearing sick’. These factors are difficult to quantify. A risk score combining objective, validated factors of ACS and the physician’s subjective, unstructured clinical gestalt is suggested. Further quantitative research is needed to verify this.

Item Type:	Thesis (Thesis)
Supervisor name:	Supervisor: and Tio, Dr. R. A. and Cardiologist and UMCG
Faculty:	Medical Sciences
Date Deposited:	25 Jun 2020 11:06
Last Modified:	25 Jun 2020 11:06
URI:	https://umcg.studenttheses.ub.rug.nl/id/eprint/2603

Actions (login required)

View Item