EVALUATING CHEST PAIN - THE PATIENTS PRESENTATION STYLE ALTERS THE PHYSICIANS DIAGNOSTIC-APPROACH

Backgrounds: Clinical prediction rules rely largely on objective data to estimate coronary artery disease (CAD) likelihood. However, charact erization of chest pain, which is central to such prediction rules, de pends in part on a physician's subjective judgments. We performed a cl inical trial to assess the influence of the patient's presentation sty le on the physician's approach to evaluating chest pain. Methods: Fort y-four internists were randomized to one of three treatment groups. Tw o groups viewed videotapes of the same actress performing the role of a patient in a scripted physician-patient interview in two distinct st yles: one group saw a 'histrionic'' characterization, the other a ''bu sinesslike' portrayal. The interviewer was not seen or heard by the su bjects; they saw only words on the screen. The third group read a verb atim transcript of the interview. After their initial CAD-likelihood e stimates and impressions of probable cause for the patient's symptoms, which were based on history only, the participants in all three group s were given the same laboratory data and a second CAD-likelihood esti mate was made. Finally, recommendations for further workup were elicit ed. Results: Initial diagnostic impressions differed dramatically: a c ardiac cause was suspected by 50% of physicians viewing the businessli ke portrayal but by only 13% of those viewing the histrionic portrayal . Likewise, those viewing the histrionic and businesslike videos provi ded different CAD-likelihood estimates initially (10% vs 20%). However , after the patient's laboratory data were revealed, the difference in CAD-likelihood estimates was no longer significant. Despite their mak ing a similar risk appraisal after receiving all of the data, internis ts viewing the histrionic portrayal were far less likely to pursue a c ardiac workup (53% vs 93%). Conclusions: Although physicians may evalu ate patients who have the same history word for word and the same labo ratory data and whom they regard as having nearly identical likelihood s of CAD, the physician's ultimate diagnostic approach can be profound ly affected by the patient's presentation style.