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Independents' Day

Trust your gut (or whatever you want to call it)

Dr David Turner

‘Have you had any symptoms in your chest?’

This was one of the more open ways of enquiring about possible cardiac symptoms that I was taught by a consultant I worked for as a young doctor.

At the beginning of this six-month job, the consultant in question told all of us juniors about his own experience of suffering an MI. The symptoms had been insidious, and the consultant hadn’t believed that they were cardiac in origin, until he reviewed his own ECG.

The recent BBC News story reporting that inequalities in heart care are costing women’s lives should make us all review how we take a cardiac history.

This consultant’s story, told to me early in my career, made me paranoid about missing an MI. I admit that I probably over-refer to the rapid access chest pain clinic, but frankly I’d rather do this than miss a case of cardiac chest pain.

In my time as a GP, I’ve seen cardiac pain present as isolated: shoulder; elbow; jaw; back and upper abdominal pain. I’ve learned never to simply ask a patient if they have had chest pain. On many occasions, the answer has been ‘no’, but on further enquiry, they’ve reported things like: ‘No, I don’t get pain, but I do get an occasional ache’.

An angry phone call from an annoyed medical registrar is infinitely better than a dead patient

I’ve heard cardiac pain described as burning; stinging; tightness; pressing; aching and every adjective in-between.

In female patients, I’ve lost count of the number of times nondescript tiredness and shortness of breath turned out to be ischaemic heart disease (IHD).

The truth is that the textbook presentation of cardiac pain, in general practice in any case, is rare.

Brought up on the acute and often dramatic A&E presentations of MI, we need to re-educate our young GPs on how much more subtle the symptoms of IHD can be in primary care. There is no substitute for experience and gut feeling - sometimes you just know it’s cardiac, even though the symptoms tick none of the boxes.

So, my message to trainees: Trust your instinct; use protocols and box-ticking forms with caution; and, if in doubt, send the patient to hospital.

An angry phone call from an annoyed medical registrar is infinitely better than a dead patient.

Dr David Turner is a GP in North West London

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Readers' comments (5)

  • Maybe the registrar should not be getting angry due to complexities of diagnosis given what you have described?

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  • Excellent advice! medical practice is highly complex and we cannot afford to have narrowed thinking in general practice. Very few signs and symptoms are pathognomonic.

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  • My most unusual presentation was "tummy bug, feels terrible, abdo pain and looks grey, has vomited" history on the phone from a carer. On arrival she looked grey and unwell but said she felt better, had low BP and very close questioning revealed "something" in chest. Paramedics were called and ECG showed ischaemia.

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  • totally agree, but referral management autobots will slap our wrists for over referral...

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  • Dr Gupta

    I wonder how AI would suspect MI in these cases...!!

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