http://informahealthcare.com/doi/full/10.3109/0142159X.2012.652709

The authors concluded that safety programs in family practice should pay more attention to establishing right diagnoses.But we believe that uncertainty and unpredictability are common in family practice and that family physicians may sometimes not yet be able to establish a diagnosis but still have to decide to intervene or to wait and watch. In family practice, a right prognosis about the course of a disease is much more important than establishing a right diagnosis.Taking time to listen, careful examination, awareness of cognitive errors such as anchoring with confirmation bias and premature closure, and taking one’s gut feelings seriously are more fruitful ways to prevent serious errors than establishing the right diagnosis.In our view, research in family practice should particularly identify which signs and symptoms are reliable indicators of the course of a disease, instead of focussing on establishing the diagnosis.

An international research group named The European Expert Group on Cognitive and Interactive Processes in Diagnosis and Management in General Practice or Cogita expert group for short, has been established in 2008. The fourth study meeting was in Krakow (Poland), on 13th and 14th October 2011. For further reading click here

Current research projects

Marburg group: video recording of 300 GP consultations and interviews afterwards.

Warwick group: analysing 100 consultations using the patient enablement instrument.

Brest group: working on a PhD protocol; sense of alarm in emergency situations.

Maastricht/Antwerp group:validation of the questionnaire finished; analysing tutorials on clinical reasoning (analytical and non-analytical reasoning); the interaction of gut feelings (GF) and other elements of clinical reasoning; studying the GF’s determinant experience; initiating GF research in the hospital specialist domains.

Presentations

• Malin Andre: ‘GPs’ medical decision-making: perceiving the patient
  as a person or a disease’. A prospective and descriptive study with a questionnaire and 16 GPs on 25 consecutive consultations. Immediate problem-solving was most frequent in somatic problems with weight on symptoms, and in psychosocial problems with weight on person. GPs seem to immediately recognize both, problems and persons. which describes expert skills of the GP.
• Teresa Pawlikowska:‘The doctor’s perspective on enabling medical consultations’. In enabling consultations, doctors do consultations with informed flexibility achieved by
  integrating their knowledge of the patient, the taxonomy of the patient’s agenda and key relational elements: trust, recognition, communication, prescribing, and time.
• Norbert Donner-Banzhoff: ‘A mathematical theory of general practice’. “Entropy is a  function of probability, measured in bits per symbol (Shannon). NDB stated that GPs are reducing uncertainty and establishing order by reducing entropy asking some specific questions, and then at a later point of consultation may refer to the specialist, who then continues with a rather ‘simple’ situation.
• Amelie Calvez: ‘GPs’ decisional criteria in emergency and the gut feelings’ place’. Observational study 2010, place: emergency and ICU Quimper hospital, Brittany. A sense of alarm occurs if there is a lack of objective criteria or there are conflicting objective criteria. Analysis of relationship between ‘stroke cases’ with and without a sense of alarm, measured and outlied in a dendrogram, failed to isolate the gut feeling cases from the others.GPs seem to switch from automatical mode into attentional mode, triggered by a sense of alarm.
• Marie Barais: reporting on several outcomes from the ‘Brest Team 2010 – 2011’. In risky environments, a sense of alarm may function as an error prevention tool. It is about systems and humans: decreasing risks by adapting systems and humans to each other.
• Johannes Hauswaldt: “Translating ‘Hier stimmt ‘was nicht’”. Translating this phrase into English with „Something is wrong“ seems not appropriate as there may be a moral connotation with „wrong“.
• Erik Stolper:‘Teaching analytic and non-analytic diagnostic reasoning in instructional dialogues in general practice’. Most of the tutorials were about management and about therapeutic approach, not about diagnostic/clinical reasoning. Found content codes (11 categories, 77 codes) and conversation codes (4 /28). There were elements of generalisation and of individualisation. Impression that In GP traineeship the emphasis is more on the individualisation compared to the general medical education.

Research ideas for future

• Linguistic validation of questionnaire in other languages and using it for further research.
• Research with case vignettes.
• Composing a narrative review on the topic.
• The use of the ‘same’ standardized patients in cross-bordering and comparative research.
• Composing a glossary of terms in the gut feelings research domain and publish it as a COGITA article (a position statement).
• Write down how we approach our field of research and publish the manuscript as a COGITA article (a position statement).
• Search for common background and cultural differences.
• Go on with yearly meetings,sharing ideas and results. Maybe, we need a symposium to present us on a better way. 
• Not only concentrating on GPs but also on other physicians.

Next meeting: 17th and 18th October 2012 in Antwerp.

Short report of the Cogita-meeting October 2010

Current research projects

Maastricht/Antwerp group: Investigation into how non-analytical aspects of diagnostic reasoning are being trained in GP training programs, identify obvious gaps and design ways to fill such gaps, using a mixture of qualitative and quantitative research methods. The aim of this research is to improve the quality of GP training programs in order to strengthen the diagnostic competence of young GPs. A gut feelings questionnaire has recently been validated using 16 case vignettes.

Marburg group: ongoing research, with real-life consultations which are video-taped, questions to the GP afterwards and also consisting of a think-aloud-protocol of the GP. Research is done in cooperation with the Gigerenzer group at Max-Planck-Institut, Berlin. Data collection is done in and around Marburg. Results are reflected back to a focus group.

Hannover group: Report of results of 9 in-depth interviews with German GPs concerning the sense of alarm is in process.

Presentations

Gut feelings as a third track in diagnostic reasoning (Margje van de Wiel, Erik Stolper): a theoretical framework to understand how gut feelings arise and function in the diagnostic reasoning process of GPs.

‘Just listen’ (Norbert Donner-Banzhoff): a model of the diagnostic process as walking on a ridge, steep in the beginning and flat further on, to the left the self limiting disease, to the right life threatening conditions, where a “red flag” would make the GP to slide to discriminate for the right.

A European research agenda on gut feelings in general practice (Erik Stolper, Paul Van Royen): 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 Breizh (Brest) group (Marie Barais, Pierre Barraine and GP-trainees): key partners Telecom Bretagne LUSSI, Centre de Simulation (CESIM), College des Hautes Etudes Médicales (CHEM). Project with Delphi consensus procedures, bibliographic work, vignettes, gut feelings and serious pathologies, how do GPs build their suspicion of pulmonary embolism.

Future programs

Using the gut feelings questionnaire in other countries: linguistic and psychometric validation necessary. Perhaps, the Dutch case vignettes are useful.

Translation of the Dutch consensus statements on gut feelings into German. Delphi consensus procedure in Germany. Reports of the gut feelings research in Europe for the German academic public.

Research into existing video tapes of consultations in general practice.

The website: a literature&refererences and a glossary will be added. Via the share point all Cogita-members will have the possibility to share information, to discuss major items and to build up a data base of relevant literature.

PhD students: Marie Barais, Pierre Barraine.

Preparing of EU-funding applications.

Background: Gut feelings in general practice have been defined as a third track by Flemish GPs working on medical decision-making and problem-solving. Sense of alarm and sense of reassurance are defined concepts obtained by a Delphi procedure with Dutch and Belgian GPs or ex-GPs involved in academic educational or research programmes. The same procedure was carried out in France among academic GPs only. In order to avoid bias of theorization, it was necessary to study the point of view of non academic GPs.

Research question: What is the definition of ‘Gut Feelings’ for non academic French GPs?

Method:Qualitative research including a Delphi consensus procedure with a heterogeneous sample of 20 French GPs, who were full time physicians and not familiar with academic research. GPs were approached by phone and 20 of 25 contacted accepted to participate. They were then visited by the researcher at their office to receive standardized explanations on the procedure. Initial Dutch statements were then submitted to the participants by mail after double translation. Each comment was discussed with the research group (6 participants) before adjusting the statement.

Results: Eight consensus criteria were obtained at the third round Delphi. General practitioners have developed their own definition of sense of alarm and reassurance. Sense of alarm means that the GP feels concerned about the health of the patient even if he does not have any objective reasons. It stimulates the GP to reformulate the diagnostic hypotheses, to conduct other forms of intervention (monitoring, paraclinical examinations, experts’ opinion). Sense of reassurance means that the GP feels confident enough to continue his management even without definitive diagnosis.

Conclusions: These criteria are similar to those developed by the Dutch and French academic GPs.

Magali Coppens et al. studied wich consensus on gut feelings in general practice in France could be obtained, using the results of the Dutch focus group research into gut feelings, and repeating the same research methods. Magali Coppens conducted a qualitative research design including a Delphi consensus procedure with a heterogeneous sample of 34 French GPs involved in university educational or research programmes. After three Delphi rounds, the researchers found 70% or greater agreement on every of the ten proposed statements. A “sense of alarm” means that the GP gets the feeling something is wrong with the patient and he therefore needs to initiate specific management to prevent health problems. A “sense of reassurance” is defined as coherence between the patient’s complaints and the doctor’s clinical observations. Though the GP lacks objective facts, he feels confident, yet with caution, about the management of the patient’s situation.

Magal Coppens et al. conluded that many similarities could be found between the Dutch and the French defining statements, with a reservation on the “sense of reassurance”, which French GPs seem to feel more cautious about. The  “sense of alarm” and the “sense of reassurance” are well-defined concepts also in France, with many similarities between the Dutch and the French statements. This seems to indicate that gut feelings is a self contained concept.

The complete thesis can be found via Sharepoint, shared documents.

Gut Feelings as a Third Track in General Practitioners’ Diagnostic Reasoning. J.Gen.Intern.Med. published on line 22/10/2010, open access: http://www.springerlink.com/content/1740385228t41618/