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Anne-Maree Kelly 
Joseph Epstein Centre for Emergency Medicine 
Research @ Western Health 
CHEST PAIN ASSESSMENT: 
IS CLIN...
OR… 
OF HORSES, ZEBRAS AND UNICORNS
PERMISSION TO USE 
Professor Kelly gives permission for this material to be used for 
educational purposes (personal or gr...
CONFLICTS OF INTEREST 
I am a recently ‘retired’ member of the core writing group for the National Heart 
Foundation/ CSAN...
THE SHAPE (AND SIZE) OF THE PROBLEM 
• Patients with chest pain are very common in Australasian emergency departments. 
• ...
THE OTHER SIDE OF THE PROBLEM 
• Claims for missed or delayed diagnosis of ACS are among the most 
common claims settled b...
RATE OF MISSED MYOCARDIAL INFARCTION 
McCarthy et al. 1993. 
1.9% (1.2-2.9%) 
Schull et al. 2006. 
2.1% (1.9-2.3%) 
Rate v...
RATE OF MISSED MYOCARDIAL INFARCTION 
McCarthy et al. 1993 
1.9% (1.2-2.9%) 
Schull et al. 2006 
2.1% (1.9-2.3%) 
Rate var...
RISK TOLERANCE FOR MISSED ACS 
• Likely to depend on your point of view: 
• Patients & families 
• Emergency physicians 
•...
WHAT DO PATIENTS THINK? 
• No Australasian data 
• Pilot study from the US (Brown et al; 2010) 
• 68 patients (31 known he...
RISK TOLERANCE MISSED ACS 
• The limited available data suggests a lack of consensus among 
emergency physicians about wha...
WHAT DOES IT ALL MEAN? 
• There is variation between emergency physicians and 
between patients about the level of accepta...
THE CHEST PAIN ASSESSMENT PROCESS 
• ECG 
• Clinical assessment 
• History 
• Physical exam 
• Biomarkers 
• Other tests (...
THE CHEST PAIN ASSESSMENT PROCESS 
• ECG 
• Clinical assessment 
• History 
• Physical exam 
• Biomarkers 
• Other tests (...
Gestalt 
/ɡəˈʃtælt/ 
A perceptual pattern possessing qualities as a whole 
that cannot be described merely as a sum of its...
IT’S ABOUT …. 
• Picking when something does not quite add up 
• Knowing when to ask/ search a bit more 
• Picking the rar...
Non-serious, non- 
ACS causes 
Myocardial infarction 
Pulmonary embolism 
Aortic dissection 
Spontaneous intramural 
oesop...
SO, WHAT GOOD IS PHYSICIAN GESTALT ? 
• In chest pain assessment, physician gestalt has been 
increasing side-lined. 
• Re...
WHAT GOOD IS PHYSICIAN GESTALT ? 
• There is a move towards risk factors, biomarkers, risk stratification 
scores, clinica...
WHAT GOOD IS PHYSICIAN GESTALT ? 
• There is a move towards risk factors, biomarkers, risk stratification 
scores, clinica...
‘TRADITIONAL’ CARDIAC RISK FACTORS 
• Traditional cardiac risk factors are associated with population risk of 
coronary ar...
THE FUTILITY OF CARDIAC RISK FACTORS 
Jayes et al. 1992 
• Question: Does the 
presence of cardiac 
risk factors increase ...
THE EVIDENCE 
Jayes et al. 1992 
• Question: Does the 
presence of cardiac 
risk factors increase 
the likelihood of 
ACS?...
GESTALT - THE EVIDENCE 
• i*trACS study 
• Gestalt = ‘noncardiac chest pain’ after 
initial assessment and ECG 
• Rate of ...
GESTALT - THE EVIDENCE 
• Multi-site prospective US study. 
• Gestalt assessment before biomarker analysis. 
• Of 293 pati...
GESTALT - THE EVIDENCE 
• Investigated gestalt + ECG vs. gestalt 
+ ECG + single troponin assay 
Body; 2014 
Sensitivity S...
GESTALT - THE EVIDENCE 
• Compared HEART score and physician 
gestalt 
• Note: The HEART score includes an 
element of phy...
GESTALT OR PREDICTION SCORES? 
HEART 
score 
AUC 
Visser 0.81 
(0.76-0.86) 
Six 0.83 
(0.81-0.85) 
GRACE 
FFE 
score 
AUC ...
WHAT ABOUT THE ‘GOOD’ STORY? 
• Young-ish patient with rapidly progressive angina on exertion 
• Discussion with Cardiolog...
THE SEARCH FOR THE ‘MAGIC’ BIOMARKER 
• Strong emphasis in cardiology research 
• Highly focussed on ‘MI’ vs. ‘no MI’ with...
THE MEDICO-LEGAL WORLD 
• Coronial case reviews 
• The commonest cases I see are of missed aortic dissection: 
• In almost...
CORONER’S RECOMMENDATION 
• Structured review of a series of cases in Victoria by Coroner Spanos has led 
to the formal co...
PROS & CONS OF CHEST PAIN PATHWAYS 
B E N E F I T S 
• Consistency 
• Promotes evidence-based 
care 
• Patient flow 
• Sta...
INCONSISTENCY OF GESTALT? 
• There is evidence that the quality of physician gestalt is not 
consistent 
• Between individ...
HOW DO WE TEACH & REFINE GESTALT? 
• Good gestalt requires high quality information gathering 
• This can be taught 
• Pre...
‘IT’S ALL ABOUT EXPERIENCE’ 
• The ‘old school’ approach has been that the development and 
maintenance of ‘gut feeling’ o...
IT’S ALL ABOUT EXPERIENCE 
• The ‘old school’ approach has been that the development and 
maintenance of ‘gut feeling’ or ...
Inappropriate 
over-confidence 
Inappropriately 
defensive practice
Time alone does not deliver high quality clinical gestalt
TEACHING CLINICAL REASONING 
• Should be thought of as a skill, not something ‘picked up as you go 
along.’ 
• Taught in m...
IMPORTANT COMPONENTS OF SKILL ACQUISITION 
• Case-based learning & discussions (individual and group) 
• Demonstration and...
REFINEMENT & MAINTENANCE OF GESTALT 
• Reflective practice. 
• Case-based discussions with peers (and trainees). 
• Active...
SUMMARY 
• In current chest pain assessment processes there is a real risk of physician 
gestalt being undervalued. 
• It ...
CONCLUSION 
• Gestalt should be re-valued in diagnostic 
processes, including chest pain assessment. 
• Active strategies ...
A PLACE FOR DINOSAURS LIKE ME .. @kellyam_je 
c
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Is clinician gestalt undervalued in chest pain assessment in ED

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This presentation discusses the role of clinician gestalt in assessment of emergency department chest pain patients. Is it accurate? How does it compare with risk scores? What are its weaknesses? Can we teach it?

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Is clinician gestalt undervalued in chest pain assessment in ED

  1. 1. Anne-Maree Kelly Joseph Epstein Centre for Emergency Medicine Research @ Western Health CHEST PAIN ASSESSMENT: IS CLINICIAN GESTALT UNDER-VALUED?
  2. 2. OR… OF HORSES, ZEBRAS AND UNICORNS
  3. 3. PERMISSION TO USE Professor Kelly gives permission for this material to be used for educational purposes (personal or group) on the basis that: •The original source is acknowledged •No liability is accepted by her for the currency or setting relevance of the content
  4. 4. CONFLICTS OF INTEREST I am a recently ‘retired’ member of the core writing group for the National Heart Foundation/ CSANZ Guidelines for the Management of Acute Coronary Syndromes (2006-2014) . The opinions expressed are my personal views and do not reflect the opinions of NHF/CSANZ. I am a member of advisory boards for AstraZeneca, Novartis and MSD with respect to cardiac therapeutics.
  5. 5. THE SHAPE (AND SIZE) OF THE PROBLEM • Patients with chest pain are very common in Australasian emergency departments. • In Victoria, of 1.5 million ED attendances annually, an estimated 37,500 patients undergo an ACS rule out process. • The ‘rule in’ rate for ACS is ~15-20%, depending on how you count. • ACS rule out usually requires a prolonged period of observation and testing. • The vast majority of patients undergo an assessment process in ED and are discharged.
  6. 6. THE OTHER SIDE OF THE PROBLEM • Claims for missed or delayed diagnosis of ACS are among the most common claims settled by insurers. • Missed ACS has serious consequences for patients/ families. • Higher rate of death and serious complications.
  7. 7. RATE OF MISSED MYOCARDIAL INFARCTION McCarthy et al. 1993. 1.9% (1.2-2.9%) Schull et al. 2006. 2.1% (1.9-2.3%) Rate varied across ED from 0% to 29%. Lower ‘miss’ rates: •High volume ED •Emergency physician supervision Wilson et al 2014. 0.52% (0-3.45%) Lower ‘miss’ rates: •Individual factors • More frequent exposure to higher chest pain acuity • ‘Board certified’ staff •Setting factors • Larger hospital • Academic centre
  8. 8. RATE OF MISSED MYOCARDIAL INFARCTION McCarthy et al. 1993 1.9% (1.2-2.9%) Schull et al. 2006 2.1% (1.9-2.3%) Rate varies across ED from 0% to 29%. Lower ‘miss’ rates: •High volume ED •Consultant supervision Wilson et al 2014. 0.52% (0-3.45%) Lower ‘miss’ rates: •Individual • More frequent exposure to higher chest pain acuity • Board certified’ staff •Setting • Larger hospital • Academic centre Increasing biomarker sensitivity
  9. 9. RISK TOLERANCE FOR MISSED ACS • Likely to depend on your point of view: • Patients & families • Emergency physicians • Cardiologists • Insurers / medico-legal system • Healthcare funders
  10. 10. WHAT DO PATIENTS THINK? • No Australasian data • Pilot study from the US (Brown et al; 2010) • 68 patients (31 known heart disease) • Median decision threshold was 6.5% (IQR 0.5-22.9%) • Most often reported value was 0.5% • 44% of patients had decision threshold at 1% or less If you knew that there was a risk of something bad happening to you related to your heart (heart attack, urgent surgery, death) at what probability of an event would you want to be admitted to the hospital rather than discharged home?’
  11. 11. RISK TOLERANCE MISSED ACS • The limited available data suggests a lack of consensus among emergency physicians about what level of risk is ‘acceptable’. • There are no published data for: • Cardiologists • Insurers / medico-legal system • Healthcare funders
  12. 12. WHAT DOES IT ALL MEAN? • There is variation between emergency physicians and between patients about the level of acceptable risk. • Both tend to favour levels ≤1% • Is this realistic or achievable? • Is this cost-effective?
  13. 13. THE CHEST PAIN ASSESSMENT PROCESS • ECG • Clinical assessment • History • Physical exam • Biomarkers • Other tests (selected cases) • Further testing for CAD • Before or after discharge • Stress ECG, nuclear medicine studies, CTCA, etc.
  14. 14. THE CHEST PAIN ASSESSMENT PROCESS • ECG • Clinical assessment • History • Physical exam • Biomarkers • Other tests (selected cases) • Further testing Identify STEMI Physician gestalt Formulation of differential diagnosis and investigation/management plan • Before or after discharge • Stress ECG, nuclear medicine studies, CTCA, etc.
  15. 15. Gestalt /ɡəˈʃtælt/ A perceptual pattern possessing qualities as a whole that cannot be described merely as a sum of its parts
  16. 16. IT’S ABOUT …. • Picking when something does not quite add up • Knowing when to ask/ search a bit more • Picking the rare from the common • Appropriately weighting the throw away comment • A feel for when an apparently well-looking patient is at serious risk • Accurately identifying low risk patients
  17. 17. Non-serious, non- ACS causes Myocardial infarction Pulmonary embolism Aortic dissection Spontaneous intramural oesophageal haematoma OF HORSES, ZEBRAS AND UNICORNS
  18. 18. SO, WHAT GOOD IS PHYSICIAN GESTALT ? • In chest pain assessment, physician gestalt has been increasing side-lined. • Reasons include: • High prevalence of ‘atypical’ symptoms of ACS • Drive to achieve lower and lower rates of missed ACS • Documented variation in practice • Medico-legal climate • Patient flow pressures
  19. 19. WHAT GOOD IS PHYSICIAN GESTALT ? • There is a move towards risk factors, biomarkers, risk stratification scores, clinical decision aids & chest pain pathways. • There focus on ACS rather than other serious diagnoses. • BUT: • Gestalt has been shown to have independent diagnostic value in other conditions, e.g. DVT and PE.
  20. 20. WHAT GOOD IS PHYSICIAN GESTALT ? • There is a move towards risk factors, biomarkers, risk stratification scores, clinical decision aids & chest pain pathways. • BUT: • Gestalt has been shown to have independent diagnostic value in other conditions, e.g. DVT and PE.
  21. 21. ‘TRADITIONAL’ CARDIAC RISK FACTORS • Traditional cardiac risk factors are associated with population risk of coronary artery disease • They are widely taught as part of the assessment chest pain patients in ED • Cardiologists place a lot of store in them!
  22. 22. THE FUTILITY OF CARDIAC RISK FACTORS Jayes et al. 1992 • Question: Does the presence of cardiac risk factors increase the likelihood of ACS? • No impact in women • Diabetes and family history minimal impact in men (low OR) Han et al. 2007 • Question: Does the number of cardiac risk factors increase the likelihood of ACS? • None vs ≥4 significant in age <40 (NLR 0.17 vs. PLR 7.39) • Limited clinical value in age >40 Schrock et al. 2011 • Question: Does the presence of cardiac risk factors increase the likelihood of a positive stress test? • AUC for diagnostic performance 0.59- 0.62.
  23. 23. THE EVIDENCE Jayes et al. 1992 • Question: Does the presence of cardiac risk factors increase the likelihood of ACS? • No impact in women • Diabetes and family history minimal impact in men (low OR) Han et al. 2007 • Question: Does the number of cardiac risk factors increase the likelihood of ACS? • None vs ≥4 significant in age <40 (NLR 0.17 vs. PLR 7.39) • Limited clinical value in age >40 Schrock et al. 2011 • Question: Does the presence of cardiac risk factors increase the likelihood of a positive stress test? • AUC for diagnostic performance 0.59- 0.62. Traditional cardiac risk factors have very limited usefulness at the individual level in ED patients with chest pain
  24. 24. GESTALT - THE EVIDENCE • i*trACS study • Gestalt = ‘noncardiac chest pain’ after initial assessment and ECG • Rate of MACE=2.8% (2.3-3.5%) • 53% of these identified in ED by biomarkers • 4 were identified with MI but discharged • Adjusted ‘miss rate’ =36/2992 = 1.2% (0.9-1.7%) Miller et al. 2004
  25. 25. GESTALT - THE EVIDENCE • Multi-site prospective US study. • Gestalt assessment before biomarker analysis. • Of 293 patients with pre-test probability of ACS by gestalt ≤ 2%; 2 MACE • Sensitivity: 96.1% (95% CI 86.5-99.5%). • Sensitivity similar to computer-based attribution matching approach and ACI-TIPI. • AUC for diagnostic performance = 0.78 (0.7- 0.86). Mitchell; 2006
  26. 26. GESTALT - THE EVIDENCE • Investigated gestalt + ECG vs. gestalt + ECG + single troponin assay Body; 2014 Sensitivity Specificity NPV Gestalt + ECG* 95 (88-99) 32 (27-37) 97 (92-99) Gestalt + ECG + troponin 100 (96-100) 28 (24-100) 100 (97-100) * Low risk defined as ‘definitely not’ and ‘probably not’ ACS Physician gestalt was independently predictive of AMI (OR 2.4; 95% CI 1.6-3.6) & MACE (OR 2; 95% CI 1.4-2.7).
  27. 27. GESTALT - THE EVIDENCE • Compared HEART score and physician gestalt • Note: The HEART score includes an element of physician gestalt • Diagnostic performance (by AUC) similar: • 0.81 (0.76-0.86) for HEART score • 0.79 (0.73-0.84) physician gestalt Visser, 2014
  28. 28. GESTALT OR PREDICTION SCORES? HEART score AUC Visser 0.81 (0.76-0.86) Six 0.83 (0.81-0.85) GRACE FFE score AUC Kelly 0.74 (0.62-0.86) GRACE RISK score AUC Cullen 0.83 (0.79-0.86) Lyon 0.80 (0.75-0.85) NHF score AUC Burkett 0.54 (0.45-0.63) Cullen 0.75 (0.70-0.80) TIMI score AUC Burkett 0.71 (0.63-0.79) Cullen 0.79 (0.74-0.83) Lyon 0.76 (0.74-0.85) Six 0.75 (0.72-0.77) Gestalt AUC Mitchell 0.78 (0.70-0.80) Body 0.76 (0.70-0.82) Visser 0.79 (0.73-0.84) Clinical bottom line: • Not much difference between gestalt and prediction scores • Both are unsuitable for use alone to identify low risk group for early discharge
  29. 29. WHAT ABOUT THE ‘GOOD’ STORY? • Young-ish patient with rapidly progressive angina on exertion • Discussion with Cardiology punctuated by the questions: • What are his cardiac risk factors? • What is the troponin? • Often we have to fight to get the patient admitted for early angiography. • We are proved ‘right’ the vast majority of the time.
  30. 30. THE SEARCH FOR THE ‘MAGIC’ BIOMARKER • Strong emphasis in cardiology research • Highly focussed on ‘MI’ vs. ‘no MI’ with emphasis on early detection of MI • Fail to consider the need to rule out other diagnostic possibilities • Lack of specificity of biomarkers is problematic • They are interested in rule in and we are interested in rule out
  31. 31. THE MEDICO-LEGAL WORLD • Coronial case reviews • The commonest cases I see are of missed aortic dissection: • In almost all cases, patients presented with chest pain of some sort. • In the majority, patients were managed according to chest pain (rule out ACS) pathways. • In the majority, there were important clues in the clinical information that were either not elicited or incorrectly interpreted.
  32. 32. CORONER’S RECOMMENDATION • Structured review of a series of cases in Victoria by Coroner Spanos has led to the formal coronial recommendation to hospitals, ACEM and the Department of Health that chest pain pathways include reminders to consider other important serious diagnoses such as aortic dissection or pulmonary embolism.
  33. 33. PROS & CONS OF CHEST PAIN PATHWAYS B E N E F I T S • Consistency • Promotes evidence-based care • Patient flow • Standard documentation • Can be multidisciplinary • Tool for quality and research analysis R I S K S • Can get out of date quickly • Can promote cognitive error • Diagnostic momentum • Premature closure, etc.
  34. 34. INCONSISTENCY OF GESTALT? • There is evidence that the quality of physician gestalt is not consistent • Between individuals • Lower missed MI rates in ‘board certified’ & those assessing high risk chest pain regularly • Between settings • Lower missed MI rates in larger centres & in academic centres
  35. 35. HOW DO WE TEACH & REFINE GESTALT? • Good gestalt requires high quality information gathering • This can be taught • Pressures of ED promote short-cuts in information gathering • Gestalt also requires integration of data and appropriate clinical reasoning • Not just history and exam • From all senses and what is ‘said’ and ‘not said’ • Awareness of context • Balance of intuition and analysis
  36. 36. ‘IT’S ALL ABOUT EXPERIENCE’ • The ‘old school’ approach has been that the development and maintenance of ‘gut feeling’ or ‘gestalt’ is all about experience. • The more experience you have, the better your gut feeling will be. • Little attention to the quality of the experience and how it is integrated into future practice.
  37. 37. IT’S ALL ABOUT EXPERIENCE • The ‘old school’ approach has been that the development and maintenance of ‘gut feeling’ or ‘gestalt’ is all about experience. • The more experience you have, the better your gut feeling will be. • Little attention to the quality of the experience and how it is integrated into future practice. Slow, inefficient, unstructured, open to bias & over-weighting of selected experiences
  38. 38. Inappropriate over-confidence Inappropriately defensive practice
  39. 39. Time alone does not deliver high quality clinical gestalt
  40. 40. TEACHING CLINICAL REASONING • Should be thought of as a skill, not something ‘picked up as you go along.’ • Taught in medical schools but teaching needs to continue throughout training. • Takes effort to structure into emergency department processes. • New ACEM workplace-based assessments will hopefully foster better teaching of clinical reasoning.
  41. 41. IMPORTANT COMPONENTS OF SKILL ACQUISITION • Case-based learning & discussions (individual and group) • Demonstration and de-construction of ‘expert’ clinical reasoning • Observed clinical encounters with discussion of ‘what were you thinking then’ & feedback • Encouraging follow-up of cases to check ‘accuracy’ • Teaching reflective practice skills • Teaching about cognitive error (and strategies to mitigate it)
  42. 42. REFINEMENT & MAINTENANCE OF GESTALT • Reflective practice. • Case-based discussions with peers (and trainees). • Active (constructive) learning from adverse events/ error/ complaints. • Case follow-up. • Developing awareness of individual cognitive biases.
  43. 43. SUMMARY • In current chest pain assessment processes there is a real risk of physician gestalt being undervalued. • It is particularly important for evaluating and managing the risk of serious non- ACS conditions. • In ACS, there is evidence that it can have similar accuracy to other risk stratification tools. • When used in combination with ECG and a single troponin can accurately identify a very low risk group for ACS. • BUT • There is variation in the quality of gestalt –individual & setting factors. • Teaching and maintaining high quality gestalt is challenging in ED setting.
  44. 44. CONCLUSION • Gestalt should be re-valued in diagnostic processes, including chest pain assessment. • Active strategies to develop and refine gestalt should be part of education and continuing professional development programs.
  45. 45. A PLACE FOR DINOSAURS LIKE ME .. @kellyam_je c

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