Margje Van de Wiel

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.

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

BackgroundFamily 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.MethodsWe 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.ResultsAs 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.ConclusionsThe questionnaire appears to be valid. It enables quantitative research into the role of gut feelings and their diagnostic value in family physicians’ diagnostic reasoning.

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.

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.

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.

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 some researchers who have reported a monotonically increasing recall with level of expertise.

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

Medical Education 2011: 45: 280–288

Quality of feedback following performance assessments: does assessor expertise matter?

Purpose – This study aims to investigate quality of feedback as offered by supervisor-assessors with varying levels of assessor expertise following assessment of performance in residency training in a health care setting. It furthermore investigates if and how different levels of assessor expertise influence feedback characteristics. Design/methodology/approach – Experienced (n=18) and non-experienced (n=16) supervisor-assessors with different levels of assessor expertise in general practice (GP) watched two videotapes, each presenting a trainee in a “real-life” patient encounter. After watching each videotape, participants documented performance ratings, wrote down narrative feedback comments and verbalized their feedback. Deductive content analysis of feedback protocols was used to explore quality of feedback. Between-group differences were assessed using qualitative-based quantitative analysis of feedback data. Findings – Overall, specificity and usefulness of both written and verbal feedback was limit...

Assessing Knowledge Structures in a Constructive Statistical Learning Environment

In this report, the method of free recall is put forward as a tool to evaluate a prototypical statistical learning environment. A number of students from the faculty of Health Sciences, Maastricht University, the Netherlands, were required to write down whatever they could remember of a statistics course in which they had participated. By means of examining the free recall protocols of the participants, insight can be obtained into the mental representations they had formed with respect to three statistical concepts. Quantitative as well as qualitative analyses of the free recall protocols showed that the effect of the constructive learning environment was not in line with the expectations. Despite small-group discussions on the statistical concepts, students appeared to have disappointingly low levels of conceptual understanding.