Journal of General Internal Medicine

, Volume 10, Issue 10, pp 557–564 | Cite as

Triage decisions for emergency department patients with chest pain

Do physicians’ risk attitudes make the difference?
  • Steven D. Pearson
  • Lee Goldman
  • E. John Orav
  • Edward Guadagnoli
  • Tomas B. Garcia
  • Paula A. Johnson
  • Thomas H. Lee
Original Articles


OBJECTIVE: To determine whether physicians’ risk attitudes correlate with their triage decisions for emergency department patients with acute chest pain.

DESIGN: Cohort.

SETTING: The emergency department of a university teaching hospital.

PATIENTS: Patients presenting to the emergency department with a chief complaint of acute chest pain.

PHYSICIANS: All physicians who were primarily responsible for the emergency department triage of at least one patient with acute chest pain from July 1990 to July 1991.

METHODS: The physicians’ risk attitudes were assessed by two methods: 1) a new, six-question risk-taking scale adapted from the Jackson Personality Index (JPI), and 2) the Stress from Uncertainty Scale (SUS).

RESULTS: The physicians who had high risk-taking scores (“risk seekers”) admitted only 31% of the patients they evaluated, compared with admission rates of 44% for the medium scorers and 53% for the physicians who had low risk-taking scores (“risk avoiders”), p<0.001. After adjustment for clinical factors, the patients triaged by the risk-seeking physicians had half the odds of admission [odds ratio (OR) 0.51, 95% confidence interval (95% CI) 0.27 to 0.97], and the patients triaged by the risk-avoiding physicians had nearly twice the odds of admission (OR 1.83, 95% CI 1.10 to 3.03) of the patients triaged by the medium-risk scoring physicians. The SUS did not correlate significantly with admission rates. Of the 92 patients released home by the risk-seeking physicians, 91 (99%) were known to be alive four to six weeks afterwards and one was lost to follow-up; among the 66 patients released by the risk-avoiding physicians, 64 (97%) were known to be alive at four to six weeks, one was lost to follow-up, and one died of ischemic heart disease during a subsequent hospitalization (p=NS).

CONCLUSIONS: The physicians’ risk attitudes as measured by a brief risk-taking scale correlated significantly with then-rates of admission for emergency department patients with acute chest pain. These data do not suggest that the risk-seeking physicians achieved lower admission rates by releasing more patients who needed to be in the hospital, but an adequate evaluation of the appropriateness of triage decisions of risk-seeking and risk-avoiding physicians will require further study.

Key words

physician attitudes risk triage decision making emergency department 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Eddy DM. Variations in physician practice: the role of uncertainty. Health Aff. 1984;74:74–89.CrossRefGoogle Scholar
  2. 2.
    Fox RC. Training for uncertainty. In: Merton RK, Reader GG. Kendall PL (eds). The Student Physician. Cambridge. MA: Harvard University Press. 1957.Google Scholar
  3. 3.
    Wennberg JE, Barnes VA, Zubkoff M. Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med. 1982;16:811–24.PubMedCrossRefGoogle Scholar
  4. 4.
    Epstein AM, Begg CB, McNeil BJ. The effects of physicians’ training and personality on test ordering for ambulatory patients. Am J Public Health. 1984;74:1271–3.PubMedGoogle Scholar
  5. 5.
    Nightingale SD. Risk preference and admitting rates of emergency room physicians. Med Care. 1988;26:84–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Holtgrave DR, Lawler F. Spann SJ. Physicians’ risk attitudes, laboratory usage, and referral decisions: the case of an academic family practice center. Med Decis Making. 1991;11:125–30.PubMedCrossRefGoogle Scholar
  7. 7.
    Gerrity MS, DeVellis RF, Earp JL. Physicians’ reactions to uncertainty in patient care: a new measure and new insights. Med Care. 1990;28:724–36.PubMedCrossRefGoogle Scholar
  8. 8.
    Geller G, Tambor ES, Chase GA, Holtzman NA. Measuring physicians’ tolerance for ambiguity and its relationship to their reported practices regarding genetic testing. Med Care. 1993;31:989–1001.PubMedCrossRefGoogle Scholar
  9. 9.
    Jackson DN. Hourany L, Vidmar NJ. A four-dimensional interpretation of risk taking. J Pers. 1972;40:433–501.CrossRefGoogle Scholar
  10. 10.
    Jackson DN. Jackson Personality Inventory Manual. Goshen, NY: Research Psychologists Press, 1975.Google Scholar
  11. 11.
    Lee TH, Pearson SD, Johnson PA, et al. Failure of information as an intervention to modify clinical management. Ann Intern Med. 1995;122:434–7.PubMedGoogle Scholar
  12. 12.
    Goldman L, Weinberg M, Weisberg M, et al. A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain. N Engl J Med. 1982;307:588–96.PubMedCrossRefGoogle Scholar
  13. 13.
    Goldman L, Cook EF, Brand DA, et al. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med. 1988;318:797–803.PubMedCrossRefGoogle Scholar
  14. 14.
    Pearson SD. Lee TH, Lindsey E, Hawkins T. Cook EF, Goldman L. The impact of membership in a health maintenance organization on hospital admission rates for acute chest pain. Health Serv Res. 1994;29:59–74.PubMedGoogle Scholar
  15. 15.
    Johnson PA, Goldman L, Orav EJ, Garcia T. Pearson SD, Lee TH. Comparison of the Medical Outcomes Study Short-Form 36-item health survey in black patients and white patients with acute chest pain. Med Care. 1995;33:145–60.PubMedCrossRefGoogle Scholar
  16. 16.
    Zeger SL, Lian KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42:121–30.PubMedCrossRefGoogle Scholar
  17. 17.
    Lee TH, Rouan G, Weisberg MC, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol. 1987;60:219–24.PubMedCrossRefGoogle Scholar
  18. 18.
    Lee TH, Juarez G. Cook EF, et al. Ruling out acute myocardial infarction. A prospective multicenter validation of a 12-hour strategy for patients at low risk. N Engl J Med. 1991;324:1239–46.PubMedCrossRefGoogle Scholar
  19. 19.
    Selker HP. Coronary care unit triage decision aids: how do we know when they work? Am J Med. 1989;87:491–3.PubMedCrossRefGoogle Scholar
  20. 20.
    Allman RM, Steinberg EP. Keruly JC, Dans PE. Physician tolerance for uncertainty: use of liver—spleen scans to detect metastases. JAMA. 1985;254:246–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Nightingale SD. Risk preference and laboratory use. Med Decis Making. 1987;7:168–72.PubMedCrossRefGoogle Scholar
  22. 22.
    Greenfield SG. Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. JAMA. 1992;267:1624–30.PubMedCrossRefGoogle Scholar

Copyright information

© Hanley & Befus, inc. 1995

Authors and Affiliations

  • Steven D. Pearson
  • Lee Goldman
    • 1
  • E. John Orav
  • Edward Guadagnoli
  • Tomas B. Garcia
  • Paula A. Johnson
  • Thomas H. Lee
  1. 1.Section for Clinical EpidemiologyBrigham and Women’s HospitalBoston

Personalised recommendations