Erik Stolper

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

BackgroundGeneral 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.ObjectiveThis paper explains how gut feelings arise and function in GPs’ diagnostic reasoning.ApproachThe paper reviews literature from medical, psychological and neuroscientific perspectives.ConclusionsGut 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.

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

BackgroundGeneral 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 determinantsMethodsQualitative research including 4 focus group discussions. A heterogeneous sample of 28 GPs. Text analysis of the focus group discussions, using a grounded theory approach.ResultsGut 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.ConclusionThe 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.

Establishing a European research agenda on 'gut feelings' in general practice. A qualitative study using the nominal group technique.

Abstract Objective: Although ‘gut feelings’ are perceived as playing a substantial role in the diagnostic reasoning of the general practitioner (GP), there is little evidence about their diagnostic and prognostic value. Consensus on both types of ‘gut feelings’ (a ‘sense of alarm’, a ‘sense of reassurance’) has enabled us to operationalize the concept. As a next step we wanted to identify research questions that are considered relevant to validate the concept of ‘gut feelings’ and to estimate its usefulness for daily practice and medical education. Moreover, we were interested in the study designs considered appropriate to study these research questions. Methods: The nominal group technique (NGT) is a qualitative research method of judgmental decision-making involving four phases: generating ideas, recording them, evaluation and prioritization. Dutch and Belgian academics whose subject is general practice (n = 18), attended one of three meetings during which NGT was used to produce a ‘research agenda’ on ‘gut feelings’. Results: NGT yielded ten research questions and nine corresponding appropriate designs on four topics, i.e. the diagnostic value of ‘gut feelings’, the validation of its determinants, the opportunities for integrating ‘gut feelings’ in medical education and a rest group. The study designs respectively included recording and follow-up of ‘gut feelings’, video recording of consultations with stimulated recall using simulated and real patients respectively, analysing trainees’ consultation stories and videos, linguistic analyses, and vignette studies. Furthermore, two experimental designs were proposed. Conclusion: A European research agenda on ‘gut feelings’ in general practice has been established and could be used in collaborative research.

Hoe pluis is het niet-pluisgevoel?

SamenvattingStolper CF, Van de Wiel MWJ, Van Royen P, Brand PLP, Dinant GJ. Hoe pluis is het niet-pluisgevoel? Huisarts Wet 2015;58(4):192-5. Veel huisartsen beschouwen het ‘pluis/niet-pluisgevoel’ als een diagnostisch kompas. Het is een in eerste instantie intuïtief gevoel, maar aan de basis ligt kennis: medische kennis, ervaringskennis en contextkennis. Het niet-pluisgevoel kan de aanzet vormen tot beredeneerd diagnostisch management, als derde denkspoor naast de besliskundige en probleemoplossende denksporen in de selectie en verwerking van relevante diagnostische informatie. In leergesprekken in de huisartsopleiding blijkt het bespreken van het niet-pluisgevoel van aios inzicht te geven in de niet-analytische aspecten van het diagnostisch denken. Er is ook een korte, gevalideerde vragenlijst om de aan- of afwezigheid van het pluis/niet-pluisgevoel in het diagnostisch denken van huisartsen vast te stellen. Ook ziekenhuisspecialisten erkennen de bruikbaarheid van het niet-pluisgevoel, maar benadrukken dat in het diagnostisch denken daarna altijd een analytische stap moet worden gezet. Evidence en skilled intuition lijken elkaar wel eens uit te sluiten, maar zij passen allebei uitstekend in het concept van evidence-based medicine. Ervaren dokters zijn diagnostici die zeer bedreven zijn geworden in het intuïtief en analytisch integreren van verschillende soorten kennis.AbstractStolper CF, Van de Wiel MWJ, Van Royen P, Brand PLP, Dinant GJ. Hoe pluis is het niet-pluisgevoel? Een wetenschappelijke beschouwing Huisarts Wet 2015;58(4):192-5. Many GPs use their gut feelings, in terms of a sense of reassurance or a sense of alarm, as a diagnostic compass. It is an initially non-analytical feeling, which can however set in train a process of rationally argued diagnostic management. The feeling is based on knowledge: medical knowledge, experiential knowledge and contextual knowledge. Gut feelings can act as a third track in diagnostic reasoning in addition to the well-known medical decision-making and medical problem-solving tracks, and thus contribute to selecting and processing relevant information in the diagnostic process. Discussing gut feelings in GP training courses provides better insights into the non-analytical aspects of the diagnostic reasoning by trainees. A short, validated questionnaire to assess the presence or absence of gut feelings in the diagnostic reasoning of GPs is available. Hospital-based specialists also acknowledge the value of gut feelings in their reasoning, but emphasize that this always needs to be followed by an analytical step in the diagnostic process. Although evidence and ‘skilled intuition’ may sometimes look like irreconcilable opposites, the combination fits in very well with the concept of evidence-based medicine. Doctors are experts on diagnostics who have become very skilled in intuitively and analytically integrating different types of knowledge.

The transculturality of 'gut feelings'. Results from a French Delphi consensus survey.

Abstract Background: General Practitioners (GPs) sometimes base their clinical decisions on ‘gut feelings.’ Research into the significance of this phenomenon with focus groups and a Delphi consensus procedure in the Netherlands provided a concept of ‘gut feelings:’ a sense of alarm, a sense of reassurance and several determinants. The transculturality of ‘gut feelings’ has been examined briefly until now as the issue is complex. Objective: To determine whether a consensus on ‘gut feelings’ in general practice in France could be obtained. Using a similar Delphi consensus procedure and the same six initial statements as in the Netherlands, and compare the French results with the seven final Dutch consensual statements. Method: Qualitative research, including a Delphi consensus procedure after a forward-backward translation (FBT) of the initial Dutch statements of ‘gut feelings.’ A heterogeneous sample of 34 French expert GPs participated. FBT of the final French statements was undertaken for a content comparison with the Dutch. Results: After three Delphi rounds, French GPs reached agreement on nine statements. Many similarities have been found between the Dutch and the French defining statements, with reservations concerning the ‘sense of reassurance,’ which French GPs seemed to feel more cautious about. Conclusion: ‘Gut feelings’ are a well-defined concept in France too. The Dutch and the French consensual statements seem very close. The transculturality of the concept is confirmed, which is a new indicator that ‘gut feelings’ are a self-contained concept.

The accuracy of the general practitioner's sense of alarm when confronted with dyspnoea and/or thoracic pain: protocol for a prospective observational study

Introduction Dyspnoea and chest pain are signs shared with multiple pathologies ranging from the benign to life-threatening diseases. Gut feelings such as the sense of alarm and the sense of reassurance are known to play a substantial role in the diagnostic reasoning of general practitioners (GPs). A Gut Feelings Questionnaire (GFQ) has been validated to measure the GPs sense of alarm. A French version of the GFQ is available following a linguistic validation procedure. The aim of the study is to calculate the diagnostic test accuracy of a GPs sense of alarm when confronted with dyspnoea and chest pain. Methods and analysis Prospective observational study. Patients aged between 18 and 80 years, consulting their GP for dyspnoea and/or thoracic pain will be considered for enrolment in the study. These GPs will have to complete the questionnaire immediately after the consultation for dyspnoea and/or thoracic pain. The follow-up and the final diagnosis will be collected 4 weeks later by phone contact with the GP or with the patient if their GP has no information. Life-threatening and non-life-threatening diseases have previously been defined according to the pathologies or symptoms in the (ICPC2) International Collegiate Programming Contest classification. Members of the research team, blinded to the actual outcomes shown on the index questionnaire, will judge each case in turn and will, by consensus, classify the expected outcomes as either life-threatening or non-life-threatening diseases. The sensitivity, the specificity, the positive and negative likelihood ratio of the sense of alarm will be calculated from the constructed contingency table. Ethics and dissemination This study was approved by the ethical committee of the University de Bretagne Occidentale. A written informed consent form will be signed and dated by GPs and patients at the beginning of the study. The results will be published in due course.

Zeldzame ziekten: een onmogelijke diagnostische opgave?

SamenvattingHendriks SA, Sollie JW, Nijnuis MG, Stolper CF. Zeldzame ziekten: een onmogelijke diagnostische opgave? Huisarts Wet 2016;59(11):498-501. Zeldzame aandoeningen zijn aandoeningen met een prevalentie van minder dan 0,5 per 1000 mensen; er zijn er bijna 8000 bekend. Het is voor een huisarts onmogelijk al deze aandoeningen zelfs maar bij benadering te kennen, maar dat is ook niet nodig. Belangrijker is het dat de huisarts tijdig aan het denken wordt gezet en getriggerd wordt tot nader onderzoek of verwijzing. De huisarts beschikt over prima diagnostische gereedschappen: ‘awareness’, het ‘plusteken’ (een opvallende combinatie van symptomen), het pluis/niet-pluisgevoel, de familieanamnese en goed luisteren naar de patiënt. Online is voldoende betrouwbare informatie te vinden om bij een vermoeden verwijzing naar de tweede of derde lijn te ondersteunen. Met tijdige diagnostiek is veel gezondheidswinst te behalen. Juist omdat genezing vaak niet mogelijk is, is de patiënt gebaat bij passende symptomatische behandeling en goede toegang tot voorzieningen. Meer nascholing op dit gebied is nodig. Het kan een uitdaging voor huisartsen zijn om dit stuk diagnostiek tot hun taak te gaan rekenen.AbstractHendriks SA, Sollie JW, Nijnuis MG, Stolper CF. Rare diseases: an impossible diagnostic challenge? Huisarts Wet 2016;59(11):498-501. Rare diseases are those with a prevalence of less than 1 in 2000 and about 8000 have been identified. While it is impossible for general practitioners (GPs) to be able to diagnose all these diseases, it is important that they are alert to possible diagnoses and order investigations or refer the patient on as soon as possible. GPs have excellent diagnostic tools – awareness, recognition of an unusual combination of signs, ‘gut feelings’, knowledge of the family history, and ability to listen to the patient. The availability of reliable online resources can back up suspicions and contribute to a timely referral to secondary or tertiary care. Limiting the diagnostic delay is important, especially because cure is often not possible and patients can benefit from appropriate symptomatic treatment and access to facilities and services. Even if the exact diagnosis is not established, patients benefit from the support and supervision provided by their GP.

The linguistic validation of the gut feelings questionnaire in three European languages

BackgroundPhysicians’ clinical decision-making may be influenced by non‐analytical thinking, especially when perceiving uncertainty. Incidental gut feelings in general practice have been described, namely, as “a sense of alarm” and “a sense of reassurance”.A Dutch Gut Feelings Questionnaire (GFQ) was developed, validated and afterwards translated into English following a linguistic validation procedure.The aims were to translate the GFQ from English into French, German and Polish; to describe uniform elements as well as differences and difficulties in the linguistic validation processes; to propose a procedural scheme for future GFQ translations into other languages.MethodsWe followed a structured, similar and equivalent procedure. Forward and backward-translations, repeated consensus procedures and cultural validations performed in six steps. Exchanges between the several research teams, the authors of the Dutch GFQ, and the translators involved continued throughout the procedure.Results12 translators, 52 GPs and 8 researchers in the field participated to the study in France, Germany, Switzerland and Poland. The collaborating research teams created three versions of the 10-item GFQ. Each research team found and agreed on compromises between comparability and similarity on one hand, and linguistic and cultural specificities on the other.ConclusionsThe gut feeling questionnaire is now available in five European languages: Dutch, English, French, German and Polish. The uniform procedural validation scheme presented, and agreed upon by the teams, can be used for the translation of the GFQ into other languages. Comparing results of research into the predictive value of gut feelings and into the significance of the main determinants in five European countries is now possible.

Hanteer de Witte Raven-aanpak

SamenvattingGraag reageren wij op het artikel ‘EBM-onderwijs in de praktijk: moeilijker dan gedacht.’1 Niet vaak zie je gerandomiseerde trials in het onderwijs met ook nog zo’n geringe uitval van deelnemers en data. Prima, die invloed van epidemiologen!

Diagnostisch denken over alledaagse ziekten

SamenvattingStolper CF, Van de Wiel MWJ, Van Royen P. Diagnostisch denken over alledaagse ziekten. Huisarts Wet 2016;59(11):478-81. Ziekten die geregeld in de huisartsenpraktijk voorkomen maar niet chronisch, acuut of mogelijk levensbedreigend zijn, noemen we alledaagse ziekten. Huisartsen lijken goed in staat te zijn om onderscheid te maken tussen alledaagse ziekten en andere, ernstiger ziektebeelden waar ingrijpen vrijwel altijd geboden is, vooral omdat zij prognostisch kunnen denken. Een bepaalde mate van diagnostische onzekerheid is kenmerkend voor het huisartsenvak. We benaderen het diagnostisch beslisproces in dit artikel vanuit drie gezichtspunten: psychologisch, besliskundig en een combinatie van beide. Skilled intuition en contextkennis zijn krachtige instrumenten waarmee huisartsen met enige zekerheid diagnostische of prognostische beslissingen kunnen nemen. Ze maken ook fouten in dat proces – wij laten zien waar het mis kan gaan en hoe dat te voorkomen is. Wij denken dat diagnostische onzekerheid een positieve rol kan spelen. Expliciet feedback zoeken op diagnostische beslissingen en de aanpak van het ziekteproces maakt leren en het ontwikkelen van expertise mogelijk.AbstractStolper CF, Van de Wiel MWJ, Van Royen P. Diagnostic thinking about everyday ailments. Huisarts Wet 2016;59(11):478-81. Everyday, or minor, ailments are those that are not chronic, acute, or potentially life-threatening. Because general practitioners can think in terms of prognosis, they are able to distinguish between minor ailments and less common, serious diseases that almost always require intervention. General practice medicine is characterized by a certain degree of diagnostic uncertainty. This article approaches the diagnostic process from three perspectives: psychological, decision-making, and a combination of the two. Skilled intuition and contextual knowledge are powerful tools that allow GPs to make diagnostic or prognostic decisions with a certain degree of certainty. Mistakes can be made, and this article shows where they might occur and how they can be avoided. Diagnostic uncertainty can have a positive role, in that explicit feedback about diagnostic decisions and disease management fosters the development of expertise.