Letters

Non-cardiac chest pain

Patients need diagnoses

Rapid access clinics lead to deskilling of general practitioners

Patients need diagnoses

EDITORWe are concerned about one of the sweeping conclusions in the editorial on non-cardiac chest pain.¹ We do not agree that "providing a diagnosis may be less important than addressing a patient's concerns and fears." Providing a diagnosis is probably the most important part of the care of such patients.

Evidence shows that angiography fails to relieve the anxiety of patients,² but the psychological and psychiatric complications of chest pain may be at least partially related to general practitioners' inability to provide a definite diagnosis. Continued prescription of antiangina drugs, and possibly failure to investigate further, contribute to continued anxiety. Patients with chest pain of non-cardiac origin need a label to hang on to.

Because there is often more than one diagnosis, we suggest using the label "chest pain of unexplained origin." A multidisciplinary approach could be useful, with particular attention being paid to psychological factors.³ Nijher et al say that an alternative non-cardiac diagnosis can be difficult to make, but it is often possible: a definite diagnosis can be reached in up 85% of patients.⁴ The impact of chest pain clinics is uncertain, and follow up for patients with non-cardiac chest pain may be of value.⁵ Certainly, as the authors say, these clinics might worsen the situation if adequate follow up is not arranged.

Adequate investigation for other physical causes of chest pain must be part of a comprehensive approach to this difficult problem.

David S Coulshed, staff specialist in cardiology. 
Department of Cardiology, Nepean Hospital, Penrith, New South Wales 2751, Australia

Guy D Eslick, gastroenterology fellow. 
eslickg{at}med.usyd.edu.au

Nicholas J Talley, professor of medicine. 
Department of Medicine, University of Sydney, Nepean Hospital, PO Box 63, Penrith

1.	Nijher G, Weinman J, Bass C, Chambers J. Chest pain in people with normal coronary anatomy. BMJ 2001; 323: 1319-1320[Free Full Text]. (8 December.)
2.	Ockene IS, Shay MJ, Alpert JS, Weiner BH, Dalen JE. Unexplained chest pain in patients with normal coronary arteriograms: a follow-up study of functional status. N Engl J Med 1980; 303: 1249-1252[Abstract].
3.	Clouse RE, Lustman PJ. Psychiatric illness and contraction abnormalities of the esophagus. N Engl J Med 1983; 309: 1337-1342[Abstract].
4.	Vantrappen G, Janssens J. Angina and esophageal paina gastroenterologist's point of view. Eur Heart J 1986; 7: 828-834[Free Full Text].
5.	Eslick GD, Coulshed DS. Rapid assessment of chest pain. BMJ 2002; 324: 422[Free Full Text]. (16 February.)

Rapid access clinics lead to deskilling of general practitioners

EDITORIn many ways the editorial about non-cardiac chest pain indicates the increasing problem of overspecialisation.¹ General practitioners are good at stopping the juggernaut of investigation at source, but this takes nerve and is sometimes seen as not doing enough. Of course the general practitioner who boldly states that chest pain is non-cardiac at the first consultation is not seen to be doing very much; the decision may be made on no more than a hunch and experience, but the potential savings in time, money, and neuroses are huge. The trouble is that the system is unforgiving if the hunch was wrong.

Rapid access clinics, be they for chest pain, breast lumps, or rectal bleeding, deskill general practitioners in dealing with these symptoms because they give easy access to decisions taken with much more information. However, the editorial shows the negative side of this process. Our hospital colleagues are less good at taking decisions with no tests, as they have to be seen to be doing everything.

I have always thought that the general practitioner system works well only because general practitioners half do things, but the benefits to patients can be huge and the savings immense. It is a question of where to draw the line. Deciding that there is probably nothing wrong takes nerve and courage. Rapid access clinics deskill this process, and the implications for the NHS are considerable in terms of resources. It is not helped by empire builders who state in the public domain that patients with certain symptoms always need extensive investigation and referral. It leaves general practitioners even more exposed.

Graeme M Mackenzie, general practitioner. 
Maryport, Cumbria CA15 8EL g.mackenzie{at}eidosnet.co.uk