Keywords:
headache - knowledge - general practitioners - neurology - emergency medical services
Palavras-chave:
cefaleia - conhecimento - clínicos gerais - neurologia - serviços médicos de emergência
Neurological complaints are frequent in general practice physician's routine, especially
those who work in emergency departments. Among them, headache is a very frequent disorder[1], which requires a certain degree of knowledge on Neurology because of its extensive
differential diagnosis. With high prevalence, it is estimated that each worker loses
at least one workday per year due to incapacitating headache[2]. Parallel to this, this symptom corresponds, in the United States, to the fifth
cause of urgency and second most common neurological complaint admitted in this department[3]. Adequate diagnoses and treatments make possible to reduce this impact on population
quality of life[4].
Classification in primary and secondary headache is important in initial evaluation.
If primary headache is confirmed, prophylaxis should be improved in order to prevent
future visits in emergency care units, while causes of secondary headache are potential
emergencies, requiring prompt diagnosis and treatment. However, evidence indicates
that there are divergences in diagnosis between generalists and neurologists[3]. Teaching about the topic in academia is unsatisfactory[4], besides there is a lack of training regarding headache to graduated professionals.
Previous findings have shown that patients with headache referral to neurologist often
occurs without necessity, leading to resources wasting[5].
Thus, it is therefore necessary to evaluate and create mechanisms to increase generalist's
knowledge about headache in order to avoid undiagnosed cases, emphasizing the need
for practice of continued medical education[6]. The objective of this study was to assess general practice physicians’ level of
knowledge about headaches, in addition to outline the profile of professionals who
attend in emergency departments, as well as the profile of their respective workplaces
in terms of neurological approach.
METHODS
The present study started after local Research Ethics Committee approval - CAAE 75384417.4.0000.5227.
All evaluated individuals gave their permission to participate through signing an
informed consent.
Participants
We included physicians who attend adult public emergency care units as general practitioners.
Exclusion criteria were professionals who have specialization, residency or qualification
as specialist in Neurology or Neurosurgery, or who are majoring these specializations.
Professionals who exclusively attend pediatric patients were also excluded from evaluation.
Testing application
A cross-sectional study was carried out through questionnaire application with questions
regarding general knowledge about headache, neurological management, and emergency
units’ general practitioners profile. The questionnaire was structured in four parts:
informed consent, followed by demographic profile analysis and by multiple-choice
questions subdivided in two stages. Initial 10 questions are about individual's perceptions
regarding their knowledge and performance and then six practical questions about headache
management in Emergency Care. Questions were elaborated by specialists. Regarding
questions about headache clinical management, adequacy of responses was analyzed according
to the National Protocol for Diagnosis and Management of Headache in Brazil Emergency
Units, published by Headache Scientific Department of Brazilian Headache Society[7]. Questions used in questionnaire are presented in Appendix 1, available at www.limuneuro.com/questionsheadache.
A pilot study was initially conducted with 10 physicians to evaluate applicability
and test understanding. Questionnaires were applied in participants' native language
(Brazilian Portuguese).
Questionnaires were applied online through Google Forms® platform. Participants were
recruited after contact with Regional Council of Medicine (CRM-PR) Department, which
disclosed the research for doctors with an active membership to CRM-PR. Responses
were collected for 60 days.
Statistical analysis
Responses frequencies were expressed as percentages, while continuous variables were
expressed as means. Categorical variables were analyzed by chi-square test, while
comparison of continuous variables was performed by Mann Whitney and ANOVA tests,
when applicable. Statistical significance value was set at 0.05.
RESULTS
Profile of the doctor who works in emergency care
One hundred and fifty-nine physicians answered the questionnaire. Participants mean
age was 31.57±7.47 years, with a female predominance (42.12% were men).
Average time since graduation is 6.31±7.25 years, of which 32.70% are majoring residency
or specialization and 40.25% are already specialists. Among the latter, the most frequent
formations were Internal Medicine (13.83%), General Surgery, and Orthopedics (both
corresponding to 6.92%). These professionals have worked in emergency department an
average of 4.83±5.52 years.
Participants' self-judgment
Participants were asked about their perceptions about own neurological skills. Responses
distribution can be verified in [Table 1].
Table 1
Participant’s judgment regarding their own knowledge.
|
Questions and options
|
Answers
|
|
1) How do you judge your knowledge in Neurology?
|
|
A
|
Excellent
|
1.3%
|
|
B
|
Good
|
38.4%
|
|
C
|
Regular
|
54.7%
|
|
D
|
Bad
|
5.6%
|
|
2) How do you judge Neurology classes content in your college?
|
|
A
|
Excellent
|
6.3%
|
|
B
|
Good
|
46.5%
|
|
C
|
Regular
|
36.5%
|
|
D
|
Bad
|
10.7%
|
|
3) Do you feel confidence performing complete neurological physical examination?
|
|
A
|
Yes
|
23.9%
|
|
B
|
No
|
20.8%
|
|
C
|
Partially
|
55.3%
|
|
4) How do you judge your knowledge about Headaches treatment?
|
|
A
|
Excellent
|
7.6%
|
|
B
|
Good
|
62.3%
|
|
C
|
Regular
|
29.5%
|
|
D
|
Bad
|
0.6%
|
When questioned about how often they feel need for Neurology specialist help, 37.74%
of participants reported needing help often or frequently. Both time since graduation
and time of work in emergency units did not correlate in a statistically significant
way with perception of greater confidence in neurological care by participating physicians
(p=0.92 and p=0.60, respectively). However, those who do not have any specialization
or are not majoring a residency were statistically significantly more confident in
neurological patients care (p=0.006). Thirteen percent of interviewees affirmed never
performing neurological physical examination, even in patients with suggestive nervous
system involvement complaints.
Structure for neurological care
Participants were also asked about emergency units’ structure. In 74.84% of them,
there is no Neurologist on duty.
When questioned about available materials for performing neurological physical examination,
49.06% reported having a reflex hammer, but only 15.72% had access to an indirect
ophthalmoscope for suspected intracranial hypertension cases evaluation, while 47.17%
reported having only a flashlight or have no material to assist neurological examination.
Regarding availability of imaging tests in units, 64.15% reported access to Computed
Tomography, only 18.24% to Magnetic Resonance Imaging, and 35.85% did not have access
to any type of neuroimaging.
Knowledge assessment
Of evaluated participants, only 31.45% knew the possibility of using chlorpromazine
in a headache care context, while 63.52% reported prescribing routine opioids for
migraine. Even when asked about medication, 32.70% of participants confused medications
used for prophylaxis with abortive therapy.
Participants were also questioned about factors they considered as “red flags” to
investigate secondary causes. Response distributions can be verified in [Figure 1].
Figure 1 Answers for “red flags”.
Still, when it comes to conduct evaluation, 16.98% of participants stated that they
would perform lumbar puncture in patients with focal neurological signs prior to neuroimaging,
12.57% would have no restrictions before prescribing triptans for migraine with brainstem
symptoms, and 25.53% did not know the possibility of migraine infarcts.
When questioned about management of chronic migraine with already known motor symptoms
in all episodes, 62.26% stated that they would perform neuroimaging tests in all episodes,
of which 75% would opt for Tomography as first choice.
DISCUSSION
Headache is a highly prevalent complaint in emergency units[3], being important the presence of general practitioners with good knowledge about
cephalalgia management in this sector.
Evaluation of medical knowledge regarding headache is scarce in literature, with only
few studies addressing this issue, but in different populations, with no focus on
emergency care. However, demographic data presented in this study are similar to previous
findings in terms of gender distribution, reflecting a process of medicine "feminization"[8]. However, an important finding was in relation to prevalence of recently graduates,
who seem to be the most frequent professional profile in these sectors, and may reflect
on provided service quality. Previous studies have shown that more than half of newly
graduated physicians work in emergency care, majoring medical residency or not[9],[10].
A possible justification for poor performance can be justified by lack of practice
and clinical experience of newly graduated professionals. Previous studies have shown
that this population is insecure when evaluating more complex clinical cases, which
require specialized medical assistance[11]. In contrast, in our study, both time of service and time since graduation did not
significantly influence the confidence of professionals. A remarkable result is that
those who do not have any specialization and are not majoring residency have shown
to be more confident in neurological patients care. This may be due to a greater contact
with emergencies by these professionals when compared to specialist physicians.
An important issue to be addressed when considering the training of general practitioners
is the "neurophobia" by graduation students and physicians[12]. Previous findings have shown that a large number of students do not feel confident
when evaluating patients with neurological complaints, which are associated with "complex
complaints"[13],[14], and may reflect the care given by newly graduated professionals. In addition, the
absence of Neurology professionals in several hospitals is a contributory factor to
disservice of qualified care.
Neurological semiology is based on detailed anamnesis and execution of an improved
physical examination[15]. Professionals' lack of confidence regarding physical neurological examination,
associated to lack of basic material to perform it, as evidenced by us, contributes
to difficulty in performing accurate diagnoses. However, in addition to semiologic
technique, an adequate care structure for medical assistance is essential, which seems
to be in scarcity. Availability of neuroimaging tests presents an uneven distribution[16]. Finally, regarding imaging tests availability, magnetic resonance imaging was configured
as the least accessible equipment, influencing posterior fossa pathologies investigation.
Regarding neuroimaging, in addition to paucity of these complementary exams when necessary
for diagnostic elucidation, it is also important to evaluate another topic: the unnecessary
exams request due to lack of preparation and lack of physical examination, which is
evidenced by our study. Inadequate imaging tests solicitation can, in addition to
causing health system financial burden[4],[17], bring harm to patients, with an increased risk of developing malignant tumors due
to radiation exposure, in case of Computed Tomography[18].
This study, however, has limitations. Physicians sampling is relatively small, and
application form may generate a selection bias, since, possibly, those who are aware
of their own difficulty in Neurology refuse to participate in test, with actual deficits
of knowledge may be underestimated.
CONCLUSION
Although cases of headache are common in emergency room, most physicians do not feel
confidence when performing neurological examination, showing lack of knowledge. Professionals'
profile who works in these departments is predominantly of recent graduates, which
may affect in some way on quality of care. There was also a lack of hospitals structure
for a complete care, whose precariousness extends from simple physical examination
instruments to imaging exams. In this context, it emphasizes importance of adequate
Neurology teaching and the need of specialists' approved protocols for guidance. In
addition, it is necessary to carry out periodic programs of continuing education,
as well as to reinforce the hospitals' structures to improve neurological patients
care.
Appendix 1. Questionnaire (native language).
Appendix 1. Questionnaire (native language).
PARTE 1 - TERMO DE CONSENTIMENTO LIVRE E ESCLARECIDO
PARTE 2 - PERFIL BIOPSICOSOCIAL
PARTE 3 - CONHECIMENTO EM NEUROLOGIA E CEFALEIAS
Instruções de preenchimento: assinalar com um X dentro dos parênteses a alternativa
desejada para a resposta.
1) Como você julga seus conhecimentos em Neurologia? (assinale apenas 1 opção)
( ) Excelentes ( ) Bons ( ) Regulares ( ) Ruins
2) Como você julga os conhecimentos em Neurologia ensinados pela sua faculdade? (assinale
apenas 1 opção)
( ) Excelentes ( ) Bons ( ) Regulares ( ) Ruins
3) Você sente segurança na realização do exame físico neurológico completo? (assinale
apenas 1 opção)
( ) Sim ( ) Não ( ) Parcialmente
4) No Pronto Atendimento em que trabalha, há um Neurologista de plantão? (assinale
apenas 1 opção)
( ) Sim ( ) Não
5) Com qual frequência você sente que necessitaria de ajuda de um especialista em
Neurologia durante o seu plantão de Pronto Atendimento? (assinale apenas 1 opção)
( ) Sempre ( ) Com frequência ( ) Raramente ( ) Nunca
6) Como você julga seus conhecimentos na abordagem de Cefaleias? (assinale apenas
1 opção)
( ) Excelentes ( ) Bons ( ) Regulares ( ) Ruins
7) Quais materiais abaixo você costuma ter à mão para realização de exame físico neurológico
durante seus plantões de Pronto Atendimento? (possível assinalar mais de uma opção)
( ) Martelo de Reflexos ( ) Diapasão ( ) Fundoscópio ( ) Algodão/Pincel ( ) Lanterna
( ) Alfinetes ( ) Nenhum dos citados ( ) Não realizo o exame
8) Quais dos seguintes exames você tem disponíveis nos locais nos quais trabalha em
PA? (possível assinalar mais de uma opção)
( ) Tomografia computadorizada ( ) Ressonância Nuclear Magnética ( ) Nenhum
9) Com qual frequência você sente necessidade de solicitar exames de imagem para pacientes
que vem ao atendimento com queixa de cefaleia? (assinale apenas 1 opção)
( ) Sempre ( ) Com frequência ( ) Raramente ( ) Nunca
10) Em quais situações você realiza o exame físico neurológico completo em pacientes
de Pronto Atendimento? (assinale apenas 1 opção)
( ) Em todos os pacientes, independente da queixa
( ) Em todos os pacientes com queixas neurológicas
( ) Em nenhum paciente, solicito logo o exame de imagem
( ) Em nenhum paciente, solicito pedido de parecer do Neurologista
( ) Em nenhum paciente, não julgo este ponto importante
PARTE 4 - QUESTÕES PRÁTICAS
Instruções de preenchimento: assinalar com um X dentro dos parênteses a alternativa
desejada para a resposta.
1) Pacientes apresentando-se em pronto socorro com migrânea clássica de forte intensidade,
com sintomas resistentes aos analgésicos simples, AINES e triptanos. Assinale as opções
que julga adequadas a serem tentadas como terapia abortiva: (possível assinalar mais
de uma opção)
( ) opioides ( ) haloperidol ( ) clorpromazina ( ) antidepressivos tricíclicos
( ) betabloqueadores ( ) nenhuma das anteriores/outras ____________________
3) Assinale, abaixo, quais sinais e sintomas que você julga como indicativos de necessidade
de investigação adicional para causas secundárias de cefaleia: (possível assinalar
mais de uma opção)
( ) Cefaleia de forte intensidade ( ) Cefaleia de início em idosos ( ) Cefaleia que
acorda o paciente a noite ( ) Escotomas cintilantes precendendo a cefaleia ( ) Cefaleia
crônica com mudança no padrão da dor ( ) Cefaleia hemicraniana ( ) Fotofobia ( ) Cefaleia
>15 vezes ao mês ( ) Alterações ao exame físico neurológico ( ) Nenhuma das acima
4) Paciente apresentando-se com cefaleia de forte intensidade. Em quais casos indicaria
uma punção lombar? (possível assinalar mais de uma opção)
( ) Caso apresente apenas febre associada, já indicaria
( ) Caso apresente apenas rigidez de nuca, já indicaria
( ) Caso apresentasse alteração focal ao exame físico neurológico, antes de exame
de imagem
( ) Caso apresentasse alteração focal ao exame físico neurológico, após exame de imagem
( ) Caso apresentasse rebaixamento do nível de consciência
( ) Nenhuma das acima
5) Paciente vem ao atendimento com queixa de cefaleia de forte intensidade, solicitando
medicação abortiva de crise. Refere que este episódio é igual aos que sempre tem -
possui diagnóstico de migrânea com aura de tronco encefálico. Quais drogas das listadas
abaixo são contraindicadas neste caso? (possível assinalar mais de uma opção)
( ) analgésicos simples ( ) antiinflamatórios não esteroidais ( ) triptanos ( ) ergotamínicos
( ) haloperidol ( ) clorpromazina ( ) opioides ( ) nenhuma das listadas, todas podem
ser utilizadas
6) A respeito da seguinte afirmativa, assinale verdadeiro ou falso: “A migrânea pode
ser complicada por isquemia de tecido encefálico”. (assinale apenas 1 opção)
( ) Verdadeiro ( ) Falso
7) Paciente vem ao atendimento em decorrência de crise de migrânea de forte intensidade,
cursando com hemiparesia a esquerda. Refere que possui crises de migrânea já há 10
anos, e que todas possuem características semelhantes ao quadro atual, com déficit
motor. Qual exame complementar você indicaria, na sala de emergência, nesta situação?
( ) Tomografia computadorizada ( ) Ressonância Magnética ( ) Não faria exames de imagem
