Performing stable angina pectoris: An ethnographic study☆
Introduction
Understanding the classification of disease (Sinding, 1989, Wailoo, 1997) and medical diagnoses (Featherstone, Latimer, Atkinson, Pilz, & Clarke, 2005; Mol & Elsman, 1996) is central to social scientific theories about the construction of medical knowledge (Armstrong, 1983, Atkinson, 1981). Even in an era when clinicians have a glittering array of diagnostic technologies at their disposal, from blood tests to imaging methods, the patient history retains a central place in diagnostic decisions. This is the case even in a specialty that avidly embraces new technologies to aid diagnosis: cardiology (Fox, 2005). This paper builds on studies in the fields of anthropology, sociology and history of medicine tracing the development and construction of a medical specialty (Wailoo, 1997), the emergence of clinical concepts (Martin, 1994) and the mutability of diseases (Sinding, 1989, Young, 1997). Here we explore the ways in which the classification of chest pain and identification of angina is accomplished within the clinical specialty of cardiology. The process of symptom classification and disease definition has consequences for patients (Bowker & Star, 1999), underpinning diagnosis and treatment within clinical practice.
Chronic angina pectoris is one of the most prevalent forms of heart disease. As well as the impact of its symptoms on quality of life, angina increases the risk of acute coronary syndromes and death in women and men (Hemingway et al., 2006). Angina is more common than a heart attack as the initial presentation of coronary disease, hence early diagnosis is important. In the initial diagnosis, clinicians discriminate between patients with underlying coronary artery disease from those with a non-cardiac cause of chest pain using the patient's description of their chest pain, particularly its quality, duration and position. There is a large quantitative literature on angina diagnosis, highlighting the central importance of the patient's history and the more limited, supportive role of non-invasive testing (Fox, 2005, Hill and Timmis, 2002). The diagnosis of angina can be problematic and the current codification of cardiac and non-cardiac chest pain may miss patients with significant coronary artery disease. In a recent study, we found that a third of fatal and non-fatal acute coronary events after onset of chronic symptoms were in patients who were thought to have non-cardiac chest pain (Sekhri, Feder, Junghans, Hemingway, & Timmis, 2006a). This mis-classification means that patients are deprived of appropriate lifestyle advice, as well as drugs and coronary revascularization which may improve symptoms of unrecognized coronary disease and prevent coronary events.
Mis-classification of symptoms as non-cardiac may occur for a number of reasons. Group differences in the way that chest pain of cardiac origin is described might contribute to ‘missed’ diagnoses. For example, women with coronary artery disease describe angina pain differently from men (Philpott, Boynton, Feder, & Hemingway, 2001) and there are gender-specific differences in risk factors, symptoms and diagnostic approaches (Shaw et al., 2006). The presentation of angina may also differ between ethnic groups. The Rose angina questionnaire performs inconsistently across ethnic groups when compared to electrocardiogram (ECG) findings (Fischbacher, Bhopal, Unwin, White, & Alberti, 2001).
Our theoretical orientation is phenomenological, focusing on clinical practice. Our perspective is that diseases are performed or enacted in interactions between doctors and patients (Mol, 2002). This perspective “…does not simply grant objects a contested and accidental history (that they acquired a while ago, with the notion of and the stories about their construction), but gives them a complex present too, a present in which their identities are fragile and may differ between sites. It does so by deploying… ethnographic methods of study… describing the various performances – or enactments - of the objects' identities on stage” (Mol, 2002, p. 43).
In this study, we focused on the first act of the performance of angina: the initial “taking” of a history by the doctor from the patient with new onset stable chest pain. By examining how patients are questioned and symptoms articulated, we made no assumptions about how they fit into disease categories. Instead, we focused on how the symptoms and categories of cardiac and non-cardiac pain were performed or enacted in the work of a cardiology clinic.
Previous qualitative research examining angina and heart disease has focused on patient beliefs, understanding and attitudes towards cardiovascular health (Emslie, 2005, French et al., 2005) but has largely ignored the clinical consultation. Those studies that have focused on the consultation have not examined the construction of diagnoses in relation to patient history (Gordon, Street, Kelly, Souchek, & Wray, 2005). The current emphasis on the history as narrative and as a means of expressing the patient's perspective focuses on the intrinsic value of this perspective rather than its contribution to diagnosis (Haidet & Paterniti, 2003). To understand how the initial distinction between angina or non-cardiac chest pain is performed or enacted in a cardiology clinic, in this paper we explore the verbal interaction between doctors and patients.
Section snippets
Methods
Non-participatory observation of a rapid access chest pain clinic was carried out within a UK teaching hospital. Somerville observed one clinical team consisting of three consultant cardiologists, two registrars, four senior house officers, six other junior doctors on short rotations and six technicians. The composition of the doctors in the clinic varied from day-to-day, as they had other duties in the hospital. Clinics were observed daily for 3–6 h over a 14-week period in 2004. In addition,
Work of the clinic
Diagnosing first presentation chest pain in ambulatory care was the central activity of the rapid access chest pain clinic (Sekhri, Feder, Junghans, Hemingway, & Timmis, 2006b). Patients attending the clinics were usually referred directly from their GP and often seen within 24 h. About half the patients had their symptoms for less than four weeks and nearly all for less than six months. The patient had an initial consultation with a junior doctor which is the focus of the analysis presented
Results
In the performance of “cardiac” and “non-cardiac chest pain”, the most striking feature of the consultations was the posing and repetition of a limited set of questions which the doctors used to structure the patient narrative. These questions invariably included enquiry about the quality and duration of the pain, followed by precipitating and relieving factors. These corresponded to the features of chronic chest pain (see Table 1) that Diamond and Forrester (1979) recommended for
Application of the canon
We observed four tactics used by doctors to apply this canon in consultations: ignoring contextual detail in the patient narrative, returning repeatedly to the limited set of questions, ignoring some non-canonical presented symptoms and, exceptionally, elicitation of symptoms outside the canon.
Ambiguity in pain narratives
We have shown how doctors used a small set of questions to distinguish patients with “cardiac” and non-cardiac pain. However, the canon was placed under stress in the face of complex pain narratives. This was reflected in the contestation of “exertion” and other terms, in uncertainty about family history, changes in pain descriptors and the additional complexity of consultations in which English was not the patient's first language. The rehearsing of the pain narrative appeared to be an
Diagnostic decision
We have shown how chest pain narratives are performed or enacted within the consultation and the tension between these emergent narratives and the diagnostic canon. Despite this tension, the aim of the clinic is to reach a decision on whether chest pain is likely to be cardiac (angina) or non-cardiac (unrelated to the heart) and this decision was made for all patients. Here we discuss the four main techniques we identified the doctors employed to make a decision on the identity of the chest
Discussion
In this paper, we have examined the first act of the performance or enactment of angina when patients with chest pain encounter a cardiologist. Our aim was to understand the diagnostic process of distinguishing cardiac from non-cardiac chest pain in the context of a rapid access chest pain clinic.
This performance was marked by the asking of a small set of questions by the doctor, to the exclusion of other aspects of the pain narrative initially presented by patients. The questions that doctors
References (45)
Diagnosis and screening of coronary artery disease
Primary Care
(2005)- et al.
The purpose of attributing cause: beliefs about the causes of myocardial infarction
Social Science & Medicine
(2005) - et al.
Physician–patient communication following invasive procedures: an analysis of post-angiogram consultations
Social Science & Medicine
(2005) - et al.
Epidemiology of angina pectoris: role of natural language processing of the medical record
American Heart Journal
(2007) - et al.
Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation study
Social Science & Medicine
(2001) - et al.
Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies
Journal of American College of Cardiology
(2006) Political anatomy of the body: Medical knowledge in Britain in the twentieth century
(1983)The rise of surveillance medicine
The clinical experience: The construction and reconstruction of medical reality
(1981)The clinical experience: The construction and reconstruction of medical reality
(1997)
Using reflexivity to optimize teamwork in qualitative research
Qualitative Health Research
The reliability of assessing the appropriateness of requested diagnostic tests
Medical Decision Making
Sorting things out: Classification and its consequences
How to improve the management of chest pain: hospitalists and use of prediction rules
Southern Medical Journal
Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease
New England Journal of Medicine
Women, men and coronary heart disease: a review of the qualitative literature
Journal of Advanced Nursing
Dysmorphology and the spectacle of the clinic
Sociology of Health and Illness
The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK
International Journal of Epidemiology
Investigation and management of chest pain
Heart
Assessment of angina pectoris after myocardial infarction: comparison of “Rose Questionnaire” with physician judgement in the beta-blocker heart attack trial
American Journal of Epidemiology
Profession of medicine: A study of the sociology of applied knowledge
Cited by (13)
Presentation of stable angina pectoris among women and South Asian people
2008, CMAJ. Canadian Medical Association JournalThe rise of non-communicable disease (NCDs) in Mozambique: decolonising gender and global health
2021, Gender and DevelopmentPresenting symptoms in men and women diagnosed with myocardial infarction using sex-specific criteria
2019, Journal of the American Heart AssociationIdentity and Appropriation in Applied Health Research
2017, Anthropology and Public Service: The UK ExperienceStudying the experience of chronic illness through grounded theory
2016, New Directions in the Sociology of Chronic and Disabling Conditions: Assaults on the LifeworldFeasibility and impact of a computerised clinical decision support system on investigation and initial management of new onset chest pain: A mixed methods study
2015, BMC Medical Informatics and Decision Making
- ☆
This study was funded by the NHS Service Delivery and Organisation R&D Programme and the Department of Health. Harry Hemingway is supported by a Public Health Career Scientist Award from the Department of Health.