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pandora rings The exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural advice particularly when exercise was promoted by the clinician.Conclusions Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re design of services without that test. Through its contribution to the patient’s history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.Article summaryArticle focusGiven the widespread use of the exercise ECG in assessments of patients with stable chest pain, this paper seeks to understand its role in the light of emerging evidence about its poor performance as a diagnostic test.This paper reports on the functions of the exercise ECG in UK chest pain clinics, highlighting those uses that go beyond its diagnostic function.This paper is part of an international debate about the appropriate initial tests for patients with new onset stable chest pain.Key messagesThe exercise ECG has additional functions that transcend its technical contribution to diagnosis: it can help clarify symptoms and other aspects of the clinical history, engage the patient in the diagnostic process, provide a context for guidance on reversible cardiovascular risk factors, be used to better involve and reassure patients and has the potential use for tailored lifestyle advice.Through its contribution to the patient’s history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients. As chest pain clinic services are re configured without the test, in line with UK national (National Institute for Health and Clinical Excellence (NICE)) guidance, these practices need to be integrated into new diagnostic pathways.Strengths and limitations of this studyA strength of our study is its ethnographic design incorporating the observation of patient clinician consultations and combining these data with interviews: we knew what participants did as well as said.The fieldwork was undertaken at a key time just before the introduction of the UK’s 2010 NICE guidelines and therefore provides an understanding of current practice that can inform their implementation.A limitation of our study is that data were collected largely from two chest pain clinics, potentially limiting the transferability of the findings, although the clinicians in the research team thought that the clinics were not atypical compared to others they had experienced.IntroductionInternationally, the exercise ECG is the most common initial test for the evaluation of stable chest pain and has been used widely for almost half a century.1 In the UK, exercise ECGs are a routinely performed, central part of patient assessment in most chest pain clinics, the main site of initial specialist referral.2The 2010 UK National Institute for Health and Clinical Excellence (NICE) guidelines recommend that exercise ECGs should no longer be used to diagnose or exclude stable angina in patients.3 4 This recommendation is based on systematic reviews showing that other investigations have greater diagnostic accuracy5 8 and may be more cost effective at detecting people who are subsequently found to have coronary artery disease.9 NICE recommends that the diagnosis of angina be based on clinical assessment alone or clinical assessment plus either anatomical imaging (eg, coronary angiogram) or functional testing (eg, stress echocardiography).Medical technologies can have many functions beyond their explicit purpose.10 Although technologies can distance the clinician from the patient, in some clinical settings, they may facilitate a closer relationship.11 Technologies, including diagnostic tests, are not neutral; they embody specific cultural values and a range of implicit and explicit functions.12 14 Ethnographic15 and sociological16 investigation of medical diagnosis reveals that this is a complex and often problematic process, in which the clinician combines results of diagnostic tests with the patient’s narrative (structured as a clinical history), implicitly or explicitly forming, weighing up and testing hypotheses.17 Clinical assessment and diagnosis takes place in specific settings in the context of a discursive and often physical relationship between clinician and patient pandora rings.