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?

1. Anne-Maree Kelly
Joseph Epstein Centre for Emergency Medicine
Research @ Western Health
CHEST PAIN ASSESSMENT:
IS CLINICIAN GESTALT UNDER-VALUED?

2. OR…
OF HORSES, ZEBRAS AND UNICORNS

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Gestalt
/ɡəˈʃtælt/
A perceptual pattern possessing qualities as a whole
that cannot be described merely as a sum of its parts

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. Non-serious, non-
ACS causes
Myocardial infarction
Pulmonary embolism
Aortic dissection
Spontaneous intramural
oesophageal haematoma
OF HORSES, ZEBRAS AND UNICORNS

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. 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. 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. ‘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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. ‘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. 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. Inappropriate
over-confidence
Inappropriately
defensive practice

39. Time alone does not deliver high quality clinical gestalt

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. 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. 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. 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. 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. A PLACE FOR DINOSAURS LIKE ME .. @kellyam_je
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