How patients in general practice voice and value their gut feelings about health: a qualitative interview study.

BACKGROUND: GPs consider their gut feelings a valuable tool in clinical reasoning. Research suggests patients' gut feelings may be a useful contribution to that process. Describing these feelings more precisely could improve primary care professionals' (PCPs) recognition of patients' gut feelings and insight into the underlying reasons. These descriptions would also enable a thorough examination of the validity of patients' gut feelings and their contribution to professionals' clinical reasoning. AIM: To gather the words and phrases that patients or their relatives use to share their gut feelings with primary care professionals and what they convey and imply. DESIGN AND SETTING: Qualitative study of Dutch and Belgian patients visiting an out-of-hours GP service or a GP's office. METHOD: Face-to-face semi-structured interviews were carried out with 47 patients. Interviews were coded using a descriptive content analysis in an iterative process until data sufficiency. RESULTS: Patients or their relatives expressed their gut feelings by using words relating to trusting or not trusting the situation, or to changes in normal patterns. Their gut feelings are most often felt as a sense of alarm. In general, patients experiencing a sense of alarm, particularly mothers of sick children, were convinced that something was wrong and had often learned to trust their gut feeling. A gut feeling was the main reason to contact a PCP. Patients generally felt that their gut feelings were taken seriously. CONCLUSION: The findings of this study provide an insight into how patients and relatives may express their gut feelings about their own or their relative's health and how they share these feelings with healthcare professionals. This may help clinicians improve their recognition of patients' gut feelings, being particularly alert to a patient or relative using phrases that relate to feelings of not trusting a situation, things seeming wrong or different from normal, and experiencing a sense of alarm. Further research should be carried out into the validity of patients' gut feelings.

How child health care physicians struggle from gut feelings to managing suspicions of child abuse.

AIM: We examined how gut feelings of child health care physicians' (CHCPs) contribute to the development of a suspicion of child abuse, how they act upon this suspicion and what barriers they experience in their management. To gain insight into the youth health care chain, we compared the diagnostic reasoning and management regarding this issue by CHCPs and family physicians (FPs). METHODS: Three focus groups, 20 CHCPs, thematic content analysis. RESULTS: A gut feeling acted as an early alert to look for the triggering cue(s), by observing more closely and asking relevant questions. CHCPs struggled to distinguish whether the situation involved child abuse or a lack of parenting skills, and how to communicate their concerns with parents. They tried to motivate parents to improve the situation, avoiding the term child abuse and considered involving the Child Abuse Counselling and Reporting Centre (CACRC) a measure of last resort only. CONCLUSION: As with FPs, gut feelings support CHCPs in becoming attentive to child abuse and to situations which can lead to child abuse. The next step, discussing their suspicion with the parents, is a difficult one, and the CACRC might actually help to make this step easier.

[Medical disciplinary boards on gut feelings]. / Horen artsen intuïtie van patiënten serieus te nemen?

Dutch medical disciplinary boards consider physicians' gut feelings an element of the professional standards. Some indications can be found in the international literature suggesting intuitive feelings of unease of patients or their relatives can also contribute to adequate diagnostics. What is the view of disciplinary boards on this? A search in the disciplinary boards' database (2010-2017) found 55 rulings where the search term 'ongerust' (worried) was related to a patient, family member or partner and 51 rulings where the term 'bezorgd' (concerned) was related to a patient, family member or partner. The disciplinary boards expect that doctors are prepared to discuss worry and concern with their patients. Additionally, they consider patients' worry and concern to be a useful part of the doctors' diagnostics, which may possibly result in reviewing the diagnosis. This is consistent with the international literature.

GPs' suspicion of child abuse: how does it arise and what is the follow-up?

Background: Child abuse is widespread, occurs in all cultures and communities, remains undiscovered in 90% of cases and has serious long-term effects. Physicians generally underidentify and underreport child abuse. To understand this low reporting rate and how the suspicion of child abuse arises, we examined GPs' experiences.Research questions: How does the suspicion of child abuse arise in GPs' diagnostic reasoning? How do they act upon their suspicion and which barriers do they encounter in their management?Methods: Twenty-six GPs participated in four focus groups. We used purposive sampling to include GPs with different levels of experience. We performed a thematic content analysis.Results: Suspicion of child abuse arose from common triggers and a gut feeling that 'something is wrong here'. GPs acted upon their suspicion by gathering more data, through history taking and physical examination. They often found it difficult to decide whether a child was abused, because parents, despite good intentions, may simply lack parenting skills and have different values. Clear signs of sexual abuse and physical violence were institutionally reported by GPs, whereas in less clear-cut cases they followed them up and built a supporting network of professionals around the family.Conclusions: A low child abuse reporting rate by GPs to CACRC does not mean a low detection rate. In trying to improve a child's situation, GPs make use of patients' trust in their doctor by involving other professionals. Awareness of the role of gut feelings in developing a suspicion may increase early detection and preventive actions.Key pointsPhysicians generally underidentify and underreport child abuse.Suspicion of child abuse arose from common triggers and a gut feeling that 'something is wrong here'.GPs acted upon their suspicion by gathering more data, through history taking and physical examination.GPs found it difficult to decide whether a child was abused, because parents, despite good intentions, may lack parenting skills.

[Gut feelings in the diagnostic reasoning process; the role of uncertainty]. / Niet-pluisgevoel in het diagnostische kenproces.

What role does uncertainty play in the doctor's diagnostic reasoning process? Would it not be better to avoid uncertainty as much as possible? In this article we answer this question from an epistemological perspective. Doctors build up relevant, situational knowledge during the diagnostic process through listening, observation and interpretation during their contact with the patient. Uncertainty can play a crucial role in this. We use a practical case to illustrate how allowing in some uncertainty - in the form of gut feelings - can improve the quality of the diagnostic thought process.

Gut Feelings Questionnaire in daily practice: a feasibility study using a mixed-methods approach in three European countries.

OBJECTIVES: The validated Gut Feelings Questionnaire (GFQ) is a 10-item questionnaire based on the definitions of the sense of alarm and the sense of reassurance. The purpose of the GFQ is to determine the presence or absence of gut feelings in the diagnostic reasoning of general practitioners (GPs).The aim was to test the GFQ on GPs, in real practice settings, to check whether any changes were needed to improve feasibility, and to calculate the prevalence of the GPs' sense of alarm and sense of reassurance in three different countries. SETTING: Primary care, six participating centres in Belgium, France and the Netherlands. PARTICIPANTS: We performed a think-aloud study with 24 experienced Dutch GPs, GP trainees and medical clerks who filled in the GFQ after diagnosing each of six case vignettes. We then performed a feasibility study in two phases, using a mixed-method approach, with 42 French and Dutch GPs in the first phase and then 10 Belgian, 10 Dutch and 10 French GPs in the second phase. All GPs filled in the GFQ after each of eight consultations with patients presenting new complaints and were subsequently interviewed about the use of the GFQ. OUTCOME MEASURES: GPs' experiences on using the GFQ in real practice, more specifically the average time needed for filling in the questionnaire.The prevalence of GPs' sense of alarm and sense of reassurance. RESULTS: The modified version of the GFQ, created without altering the sense of the validated items, was easy to use in daily practice. The prevalence of the GPs' sense of alarm occurred during 23%-31% of the included consultations. CONCLUSIONS: After a two-step study and several minor adaptations, the final version of the GFQ proved to be a feasible and practical tool to be used for prospective observational studies in daily practice.

COGITA network has constructed a glossary of diagnostic reasoning terms.

The role of gut feelings in diagnostic reasoning is recognized by most GPs throughout Europe, and probably throughout the world. Studies on this topic have emerged from different countries but there is the risk that authors will use different terms for similar concepts. The European Expert Group on Cognitive and Interactive Processes in Diagnosis and Management in General Practice, COGITA for short, was founded in 2008 to conduct cross-border research in the area of non-analytical diagnostic reasoning. Academic GPs, PhD students, psychologists, linguists and students meet once a year to share their experiences, exchange results and initiate new studies on the topic. A milestone in their research is this publication of a short glossary of diagnostic reasoning terms relating to the gut feelings research topic. It was constructed by the COGITA group members following a literature review, which aimed to define salient terms used in their publications. They described the terms, cross-reviewed the wording and reached consensus within the group. Two sections were created: (1) a diagnostic reasoning section that describes concepts such as analytical and non-analytical reasoning, clinical mind lines, and intuition, and (2) a research methods section describing concepts such as linguistic validity and saturation. The glossary, including relevant literature, has been published on the website http://www.gutfeelingsingeneralpractice.eu . In the future, the glossary will be modified if necessary and completed by members of the COGITA group. [Box: see text].

Diagnostic reasoning and underlying knowledge of students with preclinical patient contacts in PBL.

CONTEXT: Medical experts have access to elaborate and integrated knowledge networks consisting of biomedical and clinical knowledge. These coherent knowledge networks enable them to generate more accurate diagnoses in a shorter time. However, students' knowledge networks are less organised and students have difficulties linking theory and practice and transferring acquired knowledge. Therefore we wanted to explore the development and transfer of knowledge of third-year preclinical students on a problem-based learning (PBL) course with real patient contacts. METHODS: Before and after a 10-week PBL course with real patients, third-year medical students were asked to think out loud while diagnosing four types of paper patient problems (two course cases and two transfer cases), and explain the underlying pathophysiological mechanisms of the patient features. Diagnostic accuracy and time needed to think through the cases were measured. The think-aloud protocols were transcribed verbatim and different types of knowledge were coded and quantitatively analysed. The written pathophysiological explanations were translated into networks of concepts. Both the concepts and the links between concepts in students' networks were compared to model networks. RESULTS: Over the course diagnostic accuracy increased, case-processing time decreased, and students used less biomedical and clinical knowledge during diagnostic reasoning. The quality of the pathophysiological explanations increased: the students used more concepts, especially more model concepts, and they used fewer wrong concepts and links. The findings differed across course and transfer cases. The effects were generally less strong for transfer cases. CONCLUSIONS: Students' improved diagnostic accuracy and the improved quality of their knowledge networks suggest that integration of biomedical and clinical knowledge took place during a 10-week course. The differences between course and transfer cases demonstrate that transfer is complex and time-consuming. We therefore suggest offering students many varied patient contacts with the same underlying pathophysiological mechanism and encouraging students to link biomedical and clinical knowledge.

Family physicians' diagnostic gut feelings are measurable: construct validation of a questionnaire.

BACKGROUND: Family physicians perceive that gut feelings, i.e. a 'sense of reassurance' or a 'sense of alarm', play a substantial role in diagnostic reasoning. A measuring instrument is desirable for further research. Our objective is to validate a questionnaire measuring the presence of gut feelings in diagnostic reasoning. METHODS: We constructed 16 case vignettes from real practice situations and used the accompanying 'sense of reassurance' or the 'sense of alarm' as reference labels. Based on the results of an initial study (26 family physicians), we divided the case vignettes into a group involving a clear role for the sense of reassurance or the sense of alarm and a group involving an ambiguous role. 49 experienced family physicians evaluated each 10 vignettes using the questionnaire. Construct validity was assessed by testing hypotheses and an internal consistency procedure was performed. RESULTS: As hypothesized we found that the correlations between the reference labels and corresponding items were high for the clear-case vignettes (0.59 - 0.72) and low for the ambiguous-case vignettes (0.08 - 0.23). The agreement between the classification in clear sense of reassurance, clear sense of alarm and ambiguous case vignettes as derived from the initial study and the study population's judgments was substantial (Kappa = 0.62). Factor analysis showed one factor with opposites for sense of reassurance and sense of alarm items. The questionnaire's internal consistency was high (0.91). We provided a linguistic validated English-language text of the questionnaire. CONCLUSIONS: The questionnaire appears to be valid. It enables quantitative research into the role of gut feelings and their diagnostic value in family physicians' diagnostic reasoning.

Pre-clinical patient contacts and the application of biomedical and clinical knowledge.

CONTEXT: Real-patient contacts in problem-based undergraduate medical education are promoted as a good way to introduce biomedical and (in)formal clinical knowledge early in the curriculum and thereby to foster the development of coherent and integrated knowledge networks. There are concerns, however, that such contacts may cause students to focus on clinical knowledge to the neglect of biomedical knowledge, and that group discussions may be dominated by teachers. We examined these concerns by addressing the following questions in the context of group sessions in which students prepare for and report on real-patient contacts. To what extent are biomedical and (in)formal clinical knowledge addressed? To what extent are these knowledge types addressed by students or tutors? Are connections made between biomedical and clinical knowledge? METHODS: We videotaped and transcribed six preparation and six reporting group sessions (two preparation and two reporting phases for each of three groups) held with students in Year 3 of the problem-based curriculum at Maastricht University. During this year, real patients rather than paper patients are used. Qualitative analysis software was used to code propositions in the transcriptions in order to identify different kinds of knowledge and different functions of biomedical knowledge. RESULTS: Formal clinical knowledge was the subject of 40.7% and 34.8% of propositions during the preparation and reporting phases, respectively. The corresponding percentages for biomedical knowledge were 15.0% and 28.0%. Tutors accounted for 63.4% of propositions during the preparation phase, and students for 80.1% during the reporting phase. Nearly all biomedical knowledge was related to clinical knowledge. CONCLUSIONS: It appears that pre-clinical patient encounters can stimulate students to pay attention to both clinical and biomedical knowledge and to how they are connected. Tutor dominance was evident only during the preparation phase. Further research is needed to investigate whether pre-clinical patient contacts promote the development of coherent and integrated knowledge networks.

Exploring deliberate practice in medicine: how do physicians learn in the workplace?

Medical professionals need to keep on learning as part of their everyday work to deliver high-quality health care. Although the importance of physicians' learning is widely recognized, few studies have investigated how they learn in the workplace. Based on insights from deliberate practice research, this study examined the activities physicians engage in during their work that might further their professional development. As deliberate practice requires a focused effort to improve performance, the study also examined the goals underlying this behaviour. Semi-structured interviews were conducted with 50 internal medicine physicians: 19 residents, 18 internists working at a university hospital, and 13 working at a non-university hospital. The results showed that learning in medical practice was very much embedded in clinical work. Most relevant learning activities were directly related to patient care rather than motivated by competence improvement goals. Advice and feedback were sought when necessary to provide this care. Performance standards were tied to patients' conditions. The patients encountered and the discussions with colleagues about patients were valued most for professional development, while teaching and updating activities were also valued in this respect. In conclusion, physicians' learning is largely guided by practical experience rather than deliberately sought. When professionals interact in diagnosing and treating patients to achieve high-quality care, their experiences contribute to expertise development. However, much could be gained from managing learning opportunities more explicitly. We offer suggestions for increasing the focus on learning in medical practice and further research.

Gut feelings as a third track in general practitioners' diagnostic reasoning.

BACKGROUND: General practitioners (GPs) are often faced with complicated, vague problems in situations of uncertainty that they have to solve at short notice. In such situations, gut feelings seem to play a substantial role in their diagnostic process. Qualitative research distinguished a sense of alarm and a sense of reassurance. However, not every GP trusted their gut feelings, since a scientific explanation is lacking. OBJECTIVE: This paper explains how gut feelings arise and function in GPs' diagnostic reasoning. APPROACH: The paper reviews literature from medical, psychological and neuroscientific perspectives. CONCLUSIONS: Gut feelings in general practice are based on the interaction between patient information and a GP's knowledge and experience. This is visualized in a knowledge-based model of GPs' diagnostic reasoning emphasizing that this complex task combines analytical and non-analytical cognitive processes. The model integrates the two well-known diagnostic reasoning tracks of medical decision-making and medical problem-solving, and adds gut feelings as a third track. Analytical and non-analytical diagnostic reasoning interacts continuously, and GPs use elements of all three tracks, depending on the task and the situation. In this dual process theory, gut feelings emerge as a consequence of non-analytical processing of the available information and knowledge, either reassuring GPs or alerting them that something is wrong and action is required. The role of affect as a heuristic within the physician's knowledge network explains how gut feelings may help GPs to navigate in a mostly efficient way in the often complex and uncertain diagnostic situations of general practice. Emotion research and neuroscientific data support the unmistakable role of affect in the process of making decisions and explain the bodily sensation of gut feelings.The implications for health care practice and medical education are discussed.

Example-based learning: effects of model expertise in relation to student expertise.

BACKGROUND: Worked examples are very effective for novice learners. They typically present a written-out ideal (didactical) solution for learners to study. AIMS: This study used worked examples of patient history taking in physiotherapy that presented a non-didactical solution (i.e., based on actual performance). The effects of model expertise (i.e., worked example based on advanced, third-year student model or expert physiotherapist model) in relation to students' expertise (i.e., first- or second-year) were investigated. SAMPLE: One hundred and thirty-four physiotherapy students (61 first-year and 73 second-year). METHODS: Design was 2 × 2 factorial with factors 'Student Expertise' (first-year vs. second-year) and 'Model Expertise' (expert vs. advanced student). Within expertise levels, students were randomly assigned to the Expert Example or the Advanced Student Example condition. All students studied two examples (content depending on their assigned condition) and then completed a retention and test task. They rated their invested mental effort after each example and test task. RESULTS: Second-year students invested less mental effort in studying the examples, and in performing the retention and transfer tasks than first-year students. They also performed better on the retention test, but not on the transfer test. In contrast to our hypothesis, there was no interaction between student expertise and model expertise: all students who had studied the Expert examples performed better on the transfer test than students who had studied Advanced Student Examples. CONCLUSIONS: This study suggests that when worked examples are based on actual performance, rather than an ideal procedure, expert models are to be preferred over advanced student models.

Consensus on gut feelings in general practice.

BACKGROUND: General practitioners sometimes base clinical decisions on gut feelings alone, even though there is little evidence of their diagnostic and prognostic value in daily practice. Research to validate the determinants and to assess the test properties of gut feelings requires precise and valid descriptions of gut feelings in general practice which can be used as a reliable measuring instrument. RESEARCH QUESTION: Can we obtain consensus on descriptions of two types of gut feelings: a sense of alarm and a sense of reassurance? METHODS: Qualitative research including a Delphi consensus procedure with a heterogeneous sample of 27 Dutch and Belgian GPs or ex-GPs involved in academic educational or research programmes. RESULTS: After four rounds, we found 70% or greater agreement on seven of the eleven proposed statements. A "sense of alarm" is defined as an uneasy feeling perceived by a GP as he/she is concerned about a possible adverse outcome, even though specific indications are lacking: There's something wrong here. This activates the diagnostic process by stimulating the GP to formulate and weigh up working hypotheses that might involve a serious outcome. A "sense of alarm" means that, if possible, the GP needs to initiate specific management to prevent serious health problems. A "sense of reassurance" is defined as a secure feeling perceived by a GP about the further management and course of a patient's problem, even though the doctor may not be certain about the diagnosis: Everything fits in. CONCLUSION: The sense of alarm and the sense of reassurance are well-defined concepts. These descriptions enable us to operationalise the concept of gut feelings in further research.

The diagnostic role of gut feelings in general practice. A focus group study of the concept and its determinants.

BACKGROUND: General practitioners sometimes base clinical decisions on gut feelings alone, even though there is little evidence of their diagnostic and prognostic value in daily practice. Research into these aspects and the use of the concept in medical education require a practical and valid description of gut feelings. The goal of our study was therefore to describe the concept of gut feelings in general practice and to identify their main determinants METHODS: Qualitative research including 4 focus group discussions. A heterogeneous sample of 28 GPs. Text analysis of the focus group discussions, using a grounded theory approach. RESULTS: Gut feelings are familiar to most GPs in the Netherlands and play a substantial role in their everyday routine. The participants distinguished two types of gut feelings, a sense of reassurance and a sense of alarm. In the former case, a GP is sure about prognosis and therapy, although they may not always have a clear diagnosis in mind. A sense of alarm means that a GP has the feeling that something is wrong even though objective arguments are lacking. GPs in the focus groups experienced gut feelings as a compass in situations of uncertainty and the majority of GPs trusted this guide. We identified the main determinants of gut feelings: fitting, alerting and interfering factors, sensation, contextual knowledge, medical education, experience and personality. CONCLUSION: The role of gut feelings in general practice has become much clearer, but we need more research into the contributions of individual determinants and into the test properties of gut feelings to make the concept suitable for medical education.

Inducing expertise effects in clinical case recall.

BACKGROUND: This study was directed at illuminating a well known phenomenon in the medical expertise literature, the 'intermediate effect' in clinical case recall. This robust phenomenon consists of the finding that medical students of intermediate levels of expertise outperform both experts and novices in clinical case recall after diagnosing cases. It deals in particular with the findings of OME researchers who have reported a monotonically increasing recall with level of expertise. PURPOSE: To address possible causes for this anomaly in medical expertise and to experimentally demonstrate how data elaboration can cause expertise effects in clinical case recall. METHOD: Expert nephrologists, intermediate level students and novices were presented with 6 medical cases under 3 different conditions: laboratory data cases without special instructions, laboratory data cases with instructions to elaborate, and cases with laboratory data and a relevant clinical context. RESULTS: Only when participants were required to elaborate on each of the information units presented to them did case recall show an expertise effect. If laboratory data are framed within the context of a patient's history and physical examination data, the 'intermediate effect' appears. CONCLUSIONS: The instructions used in the elaboration condition seem to have induced a deeper, more detailed, analysis of the patient case. It is therefore interesting to note that these instructions only affected the recall of the experts and had no effect on the novices' or intermediates' recall. We might conclude from this that expertise effects in clinical case recall are only produced when the normal processing of patient information is disrupted.

Case representation by medical experts, intermediates and novices for laboratory data presented with or without a clinical context.

BACKGROUND: Based on cognitive psychological research, a number of theoretical frameworks have been put forward to describe the structure of experts' medical knowledge and to explain experts' case-processing. PURPOSE: To provide evidence for the theory of knowledge encapsulation, which states that medical knowledge constitutes of interlinked biomedical and clinical knowledge. METHODS: Fourth-year medical students, clerks and medical experts evaluated six case descriptions, consisting of laboratory data either with or without a clinical context. For each case description, the participants were required to study the case, to formulate a diagnosis, and to write down everything they could remember of the case. RESULTS: When the laboratory data were not embedded within a clinical context, medical experts' case-processing increased and their diagnostic accuracy became worse. Furthermore, laboratory data recall of medical experts was more elaborate in cases where the laboratory data were presented without a clinical context. Similar results were obtained for students and clerks. CONCLUSIONS: The findings are only partially consistent with a prediction made by the theory of knowledge encapsulation. Further research, using a different paradigm than the traditionally used method of free recall, is required to unearth whether medical experts use qualitatively different knowledge structures than novices while solving cases.