M. van de Wiel

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.

De overgang van theorie naar praktijk in het medisch curriculum

Er is onvoldoende bekend over de overgang in het medisch curriculum van de eerste vier, hoofdzakelijk op theoretische kennis gerichte jaren naar de vooral praktijkgerichte co-assistentschappen. De ervaringen van medisch studenten met deze overgang zijn onderzocht met behulp van focusgroepdiscussies waaraan twintig vijfdejaars studenten geneeskunde in Maastricht deelnamen. De studenten blijken een groot verschil te ervaren tussen de co-assistentschappen en de voorgaande jaren. Dit is deels toe te schrijven aan het proces van professionele socialisatie. Verder ervaren studenten hiaten in hun basiskennis en hebben ze moeite hun theoretische kennis in de praktijk toe te passen, met name bij het redeneren van symptomen naar diagnose. Dit is opmerkelijk, aangezien het probleemgestuurde onderwijs in Maastricht juist de integratie van basisvakken en klinische vakken en het leren denken vanuit symptomen zou moeten stimuleren. Een mogelijke verklaring is dat toetsing en examenreglement niet goed aansluiten bij de doelstellingen van het curriculum. Er worden suggesties gedaan hoe deze situatie verbeterd zou kunnen worden.

Het pluis/niet-pluisgevoel in het diagnostisch proces

SamenvattingHet pluis/niet-pluisgevoel (PNP) is een waardevol diagnostisch instrument in de huisartsenpraktijk. Het fenomeen wordt sinds 2005 door een groep Maastrichtse en Antwerpse onderzoekers bestudeerd. Huisartsen werden in focusgroepen bevraagd over hun ervaringen en over de betekenis die ze eraan geven. De analyse bood de basis om via een consensusprocedure het PNP-gevoel te definiëren. Met behulp van het model van duale denkprocessen is PNP theoretisch goed te begrijpen. Het bespreken van PNP in leergesprekken tussen huisarts-opleiders en huisartsen-in-opleiding bleek erg zinvol en gaf meer inzicht in het belang van intuïtie tijdens het diagnostisch proces.

EBM and gut feelings

13 International students bring in an additional dimension to the educational experience of local Chinese students particularly in regional universities. Students and the local community get an opportunity to interact with different cultures that may develop better understanding between nations. Providing a medical course in English at a non-English speaking country to overseas students is a unique concept. Chinese instructors are required to teach a distinct curriculum and lecture in a language they are not accustomed. Students often face problems in comprehending lectures and communicating effectively. Effective communication yet again becomes an obstacle when the newbie Mandarin speaking foreigners interact in the hospital. All physicians need to develop certain ‘‘core’’ competencies regardless of where they are trained from (Schwarz & Wojtczak 2002). Additionally, medical education must address the social and cultural context in which the aspiring doctors are likely to render their services. Chinese medical institutions conducting the international medical program need to make certain of a curricular content and educational process that can ensure a competent ‘‘Made in China’’ doctor.

Thirteenth tip for teaching expertise in clinical reasoning.

For years medical students worldwide have been taught the long routine of the respiratory clinical examination and rehearse it religiously so that it can be repeated in their clinical OSCE’s. However, it is unlikely that they require all aspects of the taught clinical examination to develop a differential diagnosis. There is much evidence to demonstrate that certain aspects are less reliable and have low specificity, most notably tactile vocal fremitis, whispering pectoriloquy and tracheal deviation (Benbassat and Baumal 2010). We do not teach our medical students to carry out investigations that have very low specificities, therefore why do we teach them to carry out examinations that do? We hypothesised that doctors only carry out aspects of the respiratory examination that aid diagnosis in clinical practice. To find out whether this is true, a questionnaire was sent out to all doctors in a large teaching trust. 105 responses were received from a range of different grades and specialities, including 10 respiratory specialists. The results overwhelmingly showed that the majority of doctors do not carry out tactile vocal fremitis, whispering pectoriloquy and vocal resonance and only sometimes carry out tracheal deviation. Doctors also felt less confident picking up signs with aspects of the respiratory examination that are less reliable. Medical students should be taught to perform the respiratory examination with the aim of exploring a diagnostic hypothesis. When teaching the respiratory examination, focus should be given to the more reliable aspects of the examination, which can aid the diagnosis of life threatening conditions. Less reliable aspects should be mentioned as ‘‘nice to know’’ but do not necessarily have to be performed routinely and should not be assessed in OSCE’s.