Profile and generalist physician knowledge about neurology in emergency department: headache management

Abstract Background: Neurological complaints are frequent in emergency department routine. Among them, headache is a common disorder, which requires a certain degree of knowledge on Neurology because of its extensive differential diagnosis. Objective: To assess general practice physicians’ level of knowledge about headaches, in addition to outlining the profile of professionals who attend in emergency departments, as well as the profile of their respective workplaces in terms of neurological approach. Methods: We included in evaluation physicians who attend emergency care units for adult public as general practitioners. A questionnaire was applied with questions regarding participants’ general knowledge on headache, neurological approach, demographic profile, and workplace profile. Results: 159 physicians answered the questionnaire. The professionals’ profile corresponded to recently graduated individuals (mean of 6.31 years). Knowledge about headache management was regular. Those who do not have any specialization or are not majoring a specialization were statistically significantly more confident in neurological patients care (p=0.006). Only 18.24% reported access to Magnetic Resonance Imaging and 35.85% had no access to any type of neuroimaging. Conclusions: General practice physicians often do not feel confident when performing neurological exams, demonstrating low knowledge about the topic. The profile of professionals working in these departments is predominantly of newly graduates, which may affect in some way on care quality. There was also a lack of structure for adequate care.

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.

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.
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.
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.