Marloes Amantia van Bokhoven

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.

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.

Influence of Watchful Waiting on Satisfaction and Anxiety Among Patients Seeking Care for Unexplained Complaints

PURPOSE We undertook a study to determine whether test-ordering strategy and other consultation-related factors influence satisfaction with and anxiety after a consultation among patients seeking care for unexplained complaints. METHODS A cluster-randomized clinical trial was conducted in family medicine practices in the Netherlands. Participants were 498 patients with unexplained complaints seen by 63 primary care physicians. Physicians either immediately ordered a blood test for patients or followed a 4-week watchful waiting approach. Physicians and patients completed questionnaires asking about their characteristics, satisfaction with care, and anxiety, and aspects of the consultation. The main outcomes were patient satisfaction and anxiety. Data were analyzed by multilevel logistic regression analysis. RESULTS Patients were generally satisfied with their consultation and had moderately low anxiety afterward (mean scores on 11-point scales, 7.3 and 3.1, respectively), with no difference between the immediate testing and watchful waiting groups (χ2 = 2.4 and 0.3, respectively). The factors associated with higher odds of satisfaction were mainly related to physician-patient communication: patients’ satisfaction with their physician generally, feeling taken seriously, and knowing the seriousness of complaints afterward; physicians’ discussing testing and not considering complaints bearable; and older physician age. The same was true for factors associated with higher odds of anxiety: patients expecting testing or referral, patients not knowing the seriousness of their complaints afterward, and physicians not seeing a cause for alarm. CONCLUSIONS Test-ordering strategy does not influence patients’ satisfaction with and anxiety after a consultation. Instead, specific aspects of physician-patient communication are important. Apparently, primary care physicians underestimate how much they can contribute to the well-being of their patients by discussing their worries.

Interprofessional collaboration regarding patients' care plans in primary care: a focus group study into influential factors.

BackgroundThe number of people with multiple chronic conditions demanding primary care services is increasing. To deal with the complex health care demands of these people, professionals from different disciplines collaborate. This study aims to explore influential factors regarding interprofessional collaboration related to care plan development in primary care.MethodsA qualitative study, including four semi-structured focus group interviews (n = 4). In total, a heterogeneous group of experts (n = 16) and health care professionals (n = 15) participated. Participants discussed viewpoints, barriers, and facilitators regarding interprofessional collaboration related to care plan development. The data were analysed by means of inductive content analysis.ResultsThe findings show a variety of factors influencing the interprofessional collaboration in developing a care plan. Factors can be divided into 5 key categories: (1) patient-related factors: active role, self-management, goals and wishes, membership of the team; (2) professional-related factors: individual competences, domain thinking, motivation; (3) interpersonal factors: language differences, knowing each other, trust and respect, and motivation; (4) organisational factors: structure, composition, time, shared vision, leadership and administrative support; and (5) external factors: education, culture, hierarchy, domain thinking, law and regulations, finance, technology and ICT.ConclusionsImproving interprofessional collaboration regarding care plan development calls for an integral approach including patient- and professional related factors, interpersonal, organisational, and external factors. Further, the leader of the team seems to play a key role in watching the patient perspective, organising and coordinating interprofessional collaborations, and guiding the team through developments. The results of this study can be used as input for developing tools and interventions targeted at executing and improving interprofessional collaboration related to care plan development.

Ordering blood tests for patients with unexplained fatigue in general practice: what does it yield? Results of the VAMPIRE trial

BACKGROUND Unexplained fatigue is frequently encountered in general practice. Because of the low prior probability of underlying somatic pathology, the positive predictive value of abnormal (blood) test results is limited in such patients. AIM The study objectives were to investigate the relationship between established diagnoses and the occurrence of abnormal blood test results among patients with unexplained fatigue; to survey the effects of the postponement of test ordering on this relationship; and to explore consultation-related determinants of abnormal test results. DESIGN OF STUDY Cluster randomised trial. SETTING General practices of 91 GPs in the Netherlands. METHOD GPs were randomised to immediate or postponed blood-test ordering. Patients with new unexplained fatigue were included. Limited and expanded sets of blood tests were ordered either immediately or after 4 weeks. Diagnoses during the 1-year follow-up period were extracted from medical records. Two-by-two tables were generated. To establish independent determinants of abnormal test results, a multivariate logistic regression model was used. RESULTS Data of 325 patients were analysed (71% women; mean age 41 years). Eight per cent of patients had a somatic illness that was detectable by blood-test ordering. The number of false-positive test results increased in particular in the expanded test set. Patients rarely re-consulted after 4 weeks. Test postponement did not affect the distribution of patients over the two-by-two tables. No independent consultation-related determinants of abnormal test results were found. CONCLUSION Results support restricting the number of tests ordered because of the increased risk of false-positive test results from expanded test sets. Although the number of re-consulting patients was small, the data do not refute the advice to postpone blood-test ordering for medical reasons in patients with unexplained fatigue in general practice.

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.

What makes general practitioners order blood tests for patients with unexplained complaints? A cross-sectional study.

Background: Approximately 13% of consultations in general practice involve patients with unexplained complaints (UCs). These consultations often end with general practitioners (GPs) ordering blood tests of questionable diagnostic informativeness. Objective: We studied factors potentially associated with GPs’ decisions to order blood tests. Methods: Cross-sectional study. Twenty-seven GPs completed registration forms after each consultation concerning newly presented UCs. Results: Of the 100 analysable patients, 59 had at least one blood test ordered. The median number of ordered tests was 10 (interpercentile range [IPR-90] 2–15). Compared to abdominal complaints, the blood test ordering (BTO) probability for fatigue was five times higher (relative risk [RR] 5.2). Duration of complaints for over 4 weeks also increased this probability (RR 1.6). Factors associated with a lower BTO probability were: likelihood of background psychosocial factors (RR 0.4) and GPs having a syndrome rather than symptom type of working hypothesis (RR 0.5). Conclusion: We found a high rate of BTO among GPs confronted with patients with UCs. Furthermore, a considerable number of tests were ordered. The selectivity in BTO behaviour of GPs can be improved upon.

Special methodological challenges when studying the diagnosis of unexplained complaints in primary care

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The effect of watchful waiting compared to immediate test ordering instructions on general practitioners' blood test ordering behaviour for patients with unexplained complaints; a randomized clinical trial (ISRCTN55755886)

BackgroundImmediate blood testing for patients presenting with unexplained complaints in family practice is superfluous from a diagnostic point of view. However, many general pracitioners (GPs) order tests immediately. Watchful waiting reduces the number of patients to be tested and the number of false-positive results. The objectives of this study are: to determine the feasibility of watchful waiting compared to immediate test ordering; to determine if a special quality improvement strategy can improve this feasibility; and to determine if watchful waiting leads to testing at a later time.MethodsThe study is a cluster-randomized clinical trial with three groups, on blood test ordering strategies in patients with unexplained complaints. GPs in group one were instructed to order tests immediately and GPs in group two to apply a watchful waiting approach. GPs in group three received the same instruction as group two, but they were supported by a systematically designed quality improvement strategy. A total of 498 patients with unexplained complaints from 63 practices of Dutch GPs participated. We measured: the percentage of patients for whom tests were ordered and number of tests ordered at the first consultation; performance on the strategys performance objectives (i.e., ordering fewer tests and specific communication skills); the number of tests ordered after four weeks; and GP and patient characteristics.ResultsImmediate test ordering proved feasible in 92% of the patients; watchful waiting in 86% and 84%, respectively, for groups two and three. The two watchful waiting groups did not differ significantly in the achievement of any of the performance objectives. Of the patients who returned after four weeks, none from group one and six from the two watchful waiting groups had tests ordered for them.ConclusionsWatchful waiting is a feasible approach. It does not lead to testing immediately afterwards. Furthermore, watchful waiting was not improved by the quality improvement strategy.Trial registrationClinical trial registration: ISRCTN55755886