Chest pain out-of-hours - an interview study of primary care physicians' diagnostic approach, tolerance of risk and attitudes to hospital admission

Background: Acute chest pain constitutes a considerable diagnostic challenge outside hospitals. This will often lead to uncertainty in choosing the right management, and the physicians' approach may be influenced by their knowledge of diagnostic measures and their tolerance of risk. The aim of this study was to investigate primary care physicians' diagnostic approach, tolerance of risk and attitudes to hospital admission in patients with acute chest pain out-of-hours in Norwegian primary care. Methods: Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with chest pain were analysed. Tolerance of risk was measured by the Pearson Risk Scale and the Tolerance of Risk Scale, the latter developed for this study. Results: Patient history and symptoms was considered the most important, and negative ECG and effect of sublingual nitroglycerine the least important aspects in the diagnostic approach. There were no significant differences in length of experience or gender when testing risk avoiders against the rest. Almost all physicians felt that their risk assessment out-of-hours was reasonably good, and felt reasonably safe, but only 50% agreed with the statement I don't worry about my decisions after I've made them. Concerning chest pain patients only, 51% of the physicians were worried about complaints being made about them, 75% agreed that admitting someone to hospital put patients in danger of being over-tested, and 51% were more likely to admit the patient if the patient herself wanted to be admitted. Conclusions: Physicians working out-of-hours showed considerable differences in their diagnostic approach, and not all physicians diagnose patients with chest pain according to current guidelines and evidence. Continuous medical education must focus on the diagnostic approach in patients with chest pain in primary care and empowerment of physicians through training and emphasis on risk assessment and tolerance of risk.