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.

[Diagnostic reasoning in patients with multimorbidity]. / Diagnostisch redeneren bij multimorbiditeit.

Many diseases in patients with multimorbidity show interactions, which can be divided in random, causal, complicated of synergistic interactions. Diagnostic reasoning in general should be expanded with a goal assessment when single disease directed guidelines are not applicable to limit diagnostic burden and troubling incidental findings without added diagnostic value. Disease directed diagnostic guidelines are not well adapted to symptoms and complaints of patients with multimorbidity, which urges to first explain these based on progression of the multimorbidity, and only if necessary, expand this to diagnostic work-up for new diseases. Shared decision making on additional diagnostic investigations should anticipate and safeguard added therapeutic value of diagnostic results. New instruments such as causal loop diagrams, which clarify interactions between the individual diseases, may support this multimorbidity targeted diagnostic reasoning.

[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.

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].

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.

Statistical analysis of six repertory rubrics after prospective assessment applying Bayes' theorem.

BACKGROUND: After prospective assessment of six homeopathic symptoms we validated some rubrics of the homeopathic repertory using Bayesian theory. In this paper we introduce statistical arguments for introducing or discarding entries from the repertory. METHODS: 4094 patients entered the prospective study and 4072 prescriptions were evaluated. After translating typeface into Likelihood Ratios (LRs), Confidence Intervals and the probability of existing repertory entries compared to our findings were calculated. OUTCOME: Our assessment yielded 121 relevant results to validate existing repertory entries. Five symptoms could be compared with Kent's original repertory; they have about the same prevalence (range 3.9-6.5%) in the whole population, but the size of the corresponding repertory rubrics varies from 3 to 103 entries. LR assessment reduced the larger rubrics and supplemented the smaller ones. Our results do not correspond with 56% of the existing repertory entries regarding five symptom-rubrics. This result cannot be generalised for the whole repertory.

Diagnostic test evaluation by patient-outcome study in homeopathy: balancing of feasibility and validity.

BACKGROUND: Signs and symptoms can be considered as diagnostic tests, updating prior odds by applying Bayes' theorem. In homeopathy, signs and symptoms guide the doctor when prescribing appropriate medicines but the powers of these indicators are largely based on common experience. OBJECTIVE: We want to know whether it is possible to calculate the power of arguments of signs and symptoms indicating homeopathic medicines, expressed in likelihood ratios. METHODS: An observational patient-outcome study as advocated for diagnostic test evaluation. There was no independent observation of symptoms and results. Instead, observers were extensively trained in assessing each other's cases and the process was regularly monitored. RESULTS: A total of 4072 prescriptions for 4094 patients were recorded. The relation between six clinical symptoms and outcome was calculated. Variance between observers in assessing symptoms and results were considerable. Some indications of confirmation bias were detected by follow-up, and 48 statistically significant likelihood ratios regarding six symptoms were calculated. CONCLUSION: A diagnostic patient-outcome study within homeopathy collecting a large amount of data is demonstrated. Results partly confirm clinical practice at a 95% confidence level. This kind of research could validate knowledge from practical experience.

New repertory, new considerations.

The criteria for entering medicines in repertory rubrics are unclear and partly incorrect. A new repertory should be based on clear and objective criteria. Retrospective and prospective assessment of medicines and symptoms by the Dutch Committee for Methods and Validation gives an indication of the validity of existing repertory entries. Reliance on the experience of one expert is the cause of part of the shortcomings of the repertory. This experience is highly influenced by chance. Another part is due to the use of absolute rather than relative occurrence of symptoms. Yet another part is caused by not comparing prevalence in the population 'cured' by a medicine with the remainder of the population. In many cases we need better definitions of symptoms. A clear protocol and prospective research could overcome many shortcomings of the repertory. Statistics help to get more objective criteria, but we still need to reach consensus about how to handle probabilities of outcomes of our assessments.

The 2005 meta-analysis of homeopathy: the importance of post-publication data.

BACKGROUND: There is a discrepancy between the outcome of a meta-analysis published in 1997 of 89 trials of homeopathy by Linde et al and an analysis of 110 trials by Shang et al published in 2005, these reached opposite conclusions. Important data were not mentioned in Shang et al's paper, but only provided subsequently. QUESTIONS: What was the outcome of Shang et al's predefined hypotheses? Were the homeopathic and conventional trials comparable? Was subgroup selection justified? The possible role of ineffective treatments. Was the conclusion about effect justified? Were essential data missing in the original article? METHODS: Analysis of post-publication data. Re-extraction and analysis of 21 higher quality trials selected by Shang et al with sensitivity analysis for the influence of single indications. Analysis of comparability. Sensitivity analysis of influence of subjective choices, like quality of single indications and of cut-off values for 'larger samples'. RESULTS: The quality of trials of homeopathy was better than of conventional trials. Regarding smaller trials, homeopathy accounted for 14 out of 83 and conventional medicine 2 out of 78 good quality trials with n<100. There was selective inclusion of unpublished trials only for homeopathy. Quality was assessed differently from previous analyses. Selecting subgroups on sample size and quality caused incomplete matching of homeopathy and conventional trials. Cut-off values for larger trials differed between homeopathy and conventional medicine without plausible reason. Sensitivity analyses for the influence of heterogeneity and the cut-off value for 'larger higher quality studies' were missing. Homeopathy is not effective for muscle soreness after long distance running, OR=1.30 (95% CI 0.96-1.76). The subset of homeopathy trials on which the conclusion was based was heterogeneous, comprising 8 trials on 8 different indications, and was not matched on indication with those of conventional medicine. Essential data were missing in the original paper. CONCLUSION: Re-analysis of Shang's post-publication data did not support the conclusion that homeopathy is a placebo effect. The conclusion that homeopathy is and that conventional is not a placebo effect was not based on comparative analysis and not justified because of heterogeneity and lack of sensitivity analysis. If we confine ourselves to the predefined hypotheses and the part of the analysis that is indeed comparative, the conclusion should be that quality of homeopathic trials is better than of conventional trials, for all trials (p=0.03) as well as for smaller trials (p=0.003).

A Bayesian perspective on the reliability of homeopathic repertories.

An interim assessment of likelihood ratio of homeopathic symptoms shows that there are serious flaws in Kent's repertory. The system of expressing relationship between symptoms and expected results from medicines by type-face is unclear and unreliable. Bayesian methods can improve this and expand the possibilities of the repertory including the possibility of interpreting the absence of expected symptoms.

Repertory and the symptom loquacity: some results from a pilot study on likelihood ratio.

Treatment outcome in a pilot study indicates that it is possible to assess likelihood ratios of homeopathic symptoms. Entries in repertory rubrics can be validated, but must still be handled carefully. Prospective research is the only acceptable way. Software to support this research must be carefully designed to export correct data.

Repertory and likelihood ratio: time for structural changes.

If the likelihood ratio (LR) method is introduced, the repertory will gradually change as more symptoms are assessed. It will also change the use of the repertory: the most important medicines of each symptom rubric can be identified and relied on, even in large rubrics. This is also a good opportunity to correct structural shortcomings of the repertory, for instance, entries should be based on systematic analysis of materia medica instead of casual observations.

'Cure' as the gold standard for likelihood ratio assessment: theoretical considerations.

A gold standard is necessary to assess the validity of homeopathic symptoms. The gold standard is 'cure', but this is difficult to define, and depends on consensus. The likelihood ratio (LR) method will give valid results only if the gold standard is reliable. False positives (patients incorrectly classified as cured) weaken results of LR investigation. Weakening the standard to enlarge the research population will seriously bias the results. The same gold standard should be used in LR assessment of all symptoms.

Assessing likelihood ratio of clinical symptoms: handling vagueness.

Clinical symptoms including homeopathic symptoms are often vague. There is reluctance to assess clinical symptoms as diagnostic instruments because they are hard to define. Still, clinical symptoms appear effective in daily practice. Expert systems and neural networks handle vague data successfully. Theoretical considerations predict the kind of problems we may expect. There is a difference between quantitative and qualitative vagueness. Vague data cause problems if we try to prove a hypothesis because of expectation bias. We assess likelihood ratio of homeopathic symptoms only to improve the method.

Is assessment of likelihood ratio of homeopathic symptoms possible? A pilot study.

A pilot study was performed to investigate the possibilities and restrictions of likelihood ratio (LR) investigation using three symptoms. Qualitative vagueness and expectation bias is inherent in our method, but is, in part avoidable. It appears that experienced observers assess common homeopathic symptoms quite similarly. Clinical judgement is an essential part of our work and should be preserved during assessment of LR. The assessment does not influence clinical practice and can be maintained for a long period, provided the appropriate software is used. A limited range of symptoms seems most suitable for LR investigation.