Patients' gut feelings seem useful in primary care professionals' decision making.

BACKGROUND: Family physicians' diagnostic gut feelings have proved to be valuable. But what about patients' gut feelings? Research has shown that patients' gut feelings may contribute to their physicians' clinical reasoning. Dutch medical tribunals consider patients' worry useful for doctors' diagnostic process. However, how general practitioners and other primary care professionals recognize gut feelings of patients and deal with them in their decision making is yet unclear. We aim to explore how primary care professionals perceive patients' gut feelings and use this information in their decision-making. METHODS: We interviewed 30 Dutch and Belgian primary care professionals, exploring how they recognize and value patients' gut feelings. We coded all interviews using a descriptive content analysis in an iterative process. Data sufficiency was achieved. RESULTS: Primary care professionals acknowledged gut feelings in their patients, and most participants found them a useful source of information. Patients' gut feelings might alert them to possible hidden problems and might provide quicker insight into patients' perceptions. Primary care professionals listed a whole series of wordings relating to trusting or distrusting the situation or to any changes in normal patterns. A patient's gut feeling was often a reason for the professionals to explore patients' worries and to reconsider their own clinical reasoning. CONCLUSIONS: Primary care professionals regularly considered patients' gut feelings useful, as they might contribute to their clinical reasoning and to a deeper understanding of the patient's problem. The next step could be to ask patients themselves about their gut feelings and explore their diagnostic value.

[General practitioners' recognition and management of child abuse: what is going well and what could be improved?] / Kindermishandeling herkennen en aanpakken.

In the Netherlands, child abuse affects about 100.000 children resulting in at least 17 child fatalities a year. General practitioners' (GPs) health care position is of vital importance for recognising and managing child abuse. In this Clinical Lesson, using three illustrating cases, we discuss how GPs' suspicion of child abuse may arise including the role of gut feelings, and what the mandatory national guideline on child abuse means for the follow-up. We also clarify the role of the Dutch Child Abuse Counselling and Reporting Centre (CACRC) in the process. A first lesson is that any doubts about child abuse should lead to action because diagnostic failure has serious consequences for vulnerable children. A second lesson is that asking CACRC for anonymous advice how to deal with a situation may certainly have added value. Finally, we advise CACRC to invest in building a relationship of trust with the collaborating partners.

How do gut feelings feature in tutorial dialogues on diagnostic reasoning in GP traineeship?

Diagnostic reasoning is considered to be based on the interaction between analytical and non-analytical cognitive processes. Gut feelings, a specific form of non-analytical reasoning, play a substantial role in diagnostic reasoning by general practitioners (GPs) and may activate analytical reasoning. In GP traineeships in the Netherlands, trainees mostly see patients alone but regularly consult with their supervisors to discuss patients and problems, receive feedback, and improve their competencies. In the present study, we examined the discussions of supervisors and their trainees about diagnostic reasoning in these so-called tutorial dialogues and how gut feelings feature in these discussions. 17 tutorial dialogues focussing on diagnostic reasoning were video-recorded and transcribed and the protocols were analysed using a detailed bottom-up and iterative content analysis and coding procedure. The dialogues were segmented into quotes. Each quote received a content code and a participant code. The number of words per code was used as a unit of analysis to quantitatively compare the contributions to the dialogues made by supervisors and trainees, and the attention given to different topics. The dialogues were usually analytical reflections on a trainee's diagnostic reasoning. A hypothetico-deductive strategy was often used, by listing differential diagnoses and discussing what information guided the reasoning process and might confirm or exclude provisional hypotheses. Gut feelings were discussed in seven dialogues. They were used as a tool in diagnostic reasoning, inducing analytical reflection, sometimes on the entire diagnostic reasoning process. The emphasis in these tutorial dialogues was on analytical components of diagnostic reasoning. Discussing gut feelings in tutorial dialogues seems to be a good educational method to familiarize trainees with non-analytical reasoning. Supervisors need specialised knowledge about these aspects of diagnostic reasoning and how to deal with them in medical education.

[Are postgraduate courses for GPs relevant to diagnostics?]. / Nascholing van huisartsen relevant voor diagnostiek?

Correctly predicting the course of a patient's pattern of symptoms, even if no diagnosis has (yet) been established, is a core task of the general practitioner (GP). This is a complex task requiring extensive knowledge and experience, as the presentation of diseases in primary care regularly deviates from what doctors learn at medical school. In addition, knowledge among GPs about clinical pictures requiring immediate action is not always sufficient. Finally, GPs' context and experiential knowledge are decreasing due to changes in the organization of care. In the authors' opinion, postgraduate courses for GPs insufficiently address these issues. Postgraduate courses should teach them about serious diseases that must not be missed, about uncommon presentations of common diseases and about the role of gut feelings in diagnostic thinking and the way to act on these feelings. GPs should be obliged to devote part of their compulsory postgraduate training to these subjects.

Workplace-based assessment: raters' performance theories and constructs.

Weaknesses in the nature of rater judgments are generally considered to compromise the utility of workplace-based assessment (WBA). In order to gain insight into the underpinnings of rater behaviours, we investigated how raters form impressions of and make judgments on trainee performance. Using theoretical frameworks of social cognition and person perception, we explored raters' implicit performance theories, use of task-specific performance schemas and the formation of person schemas during WBA. We used think-aloud procedures and verbal protocol analysis to investigate schema-based processing by experienced (N = 18) and inexperienced (N = 16) raters (supervisor-raters in general practice residency training). Qualitative data analysis was used to explore schema content and usage. We quantitatively assessed rater idiosyncrasy in the use of performance schemas and we investigated effects of rater expertise on the use of (task-specific) performance schemas. Raters used different schemas in judging trainee performance. We developed a normative performance theory comprising seventeen inter-related performance dimensions. Levels of rater idiosyncrasy were substantial and unrelated to rater expertise. Experienced raters made significantly more use of task-specific performance schemas compared to inexperienced raters, suggesting more differentiated performance schemas in experienced raters. Most raters started to develop person schemas the moment they began to observe trainee performance. The findings further our understanding of processes underpinning judgment and decision making in WBA. Raters make and justify judgments based on personal theories and performance constructs. Raters' information processing seems to be affected by differences in rater expertise. The results of this study can help to improve rater training, the design of assessment instruments and decision making in WBA.

The effect of guiding questions on students' performance and attitude towards statistics.

BACKGROUND: In this study, the effect of guidance on students' performance was investigated. This effect was hypothesized to be manifested through a reduction of cognitive load and enhancement of self-explanations. AIM: The goal of this study was to investigate the effect of guiding questions on students' understanding of statistics. SAMPLE AND METHOD: In an experimental setting, two randomly selected groups of students (N= 49) answered achievement and transfer questions on statistics as a measure of performance. Students in the intervention condition were given guiding questions to direct their way of reasoning before they answered the achievement questions. The students in the control condition were asked to write down their way of thinking before they answered the same achievement questions. In this way, both groups were stimulated to self-explain, but only the reasoning processes of the students in the intervention condition were guided. RESULTS AND CONCLUSION: It was found that students in the intervention condition performed significantly better on achievement and transfer questions and that this effect of guidance was mediated by self-explanations. Attitude towards statistics was positively related to performance.