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A survey of primary care physicians’ and medical students’ risk tolerance in the assessment of acute chest pain

A 2018/2019 Summer Studentship research project

This study will help us better understand clinicians’ risk tolerance in assessing patients who may have ACS. This knowledge will help us to provide education to clinicians to optimize the assessment and investigation of such patients.

Student: Richard Stewart
Supervisors: Dr Lynley Cook, Dr Ben Hudson, Dr Martin Than
Sponsor: Pegasus Health (Charatible) Limited

Project brief


Chest pain is a common presentation in primary care and though the cause is most commonly not dangerous, a proportion of patients presenting in this way will have significant pathology.  Some of these patients’ pain will be caused by acute coronary syndrome (ACS) and making or ruling out this diagnosis is important as early treatment may improve outcomes. Missing a case of ACS may lead to significant harm to the patient, and avoiding such an outcome is a major concern for clinicians faced with chest pain presentations. Faced with such a presentation, a key task for a clinician is to decide whether the probability of ACS is low enough that further investigation is not required, or that the probability is high enough that investigation (or immediate admission) is needed.

Several decision rules have been developed to help clinicians decide whether to admit or reassure patients who may have a cardiac cause for their chest pain. Many of these approaches achieve high levels of sensitivity, however none is perfect and some cases of acute cardiac syndrome will be missed.

For patients presenting to primary care with acute chest pain, there is currently no consensus on the level of risk of ACS at which further assessment is not required and the patient can be reassured. This summer student project will involve the design, distribution and analysis a survey of primary care clinicians in which we will measure risk tolerance in this type of clinical encounter. To gain insight into whether the level of risk acceptance alters with clinical experience, we will also survey GP trainees and medical students.


To determine the level of risk of missed ACS in patients presenting with acute pain at which primary care clinicians and medical students judge further assessment is unnecessary.


We will survey general practitioners (GPs), practice nurses, nurse practitioners, GP trainees and medical students using an online questionnaire.  We will collect participants’ demographic and professional details (age and gender, and professional group, years in clinical practice).

Participants will be asked to consider the assessment of a patient presenting with chest pain and to indicate the level of risk of a missed case of ACS that they would consider to be low enough not to warrant further assessment.  Participants will be asked to choose a level of risk from a range of suggested risk levels.

Student researcher’s component of the study

The student will assist in the preparation and distribution of the survey and will collate the results and perform initial analysis and interpretation of the collected data.