Gut feelings don’t stop thinking but do start thinking (Marburg conference 2015)

Saturday, April 25th, 2015

COGITA-conference March 26th 2015 in Marburg: a summary

The German Gut Feelings Questionnaire. The day started with an overview of 10 yrs Gut Feelings research by Erik Stolper. Afterwards Johannes Hauswaldt and Daniel Hausmann presented the German Gut Feelings Questionnaire. The questionnaire was translated from the English original into German at a linguistically validated way and checked by ten German general practitioners (GPs). The questionnaire consists of ten items and is appropriate for research into physician’s gut feelings, both in real life cases and when using case vignettes. Next to the German version there is a French and a Polish version. The different researchers will try to publish the linguistic validation procedure of these three versions together.

Feasibility study Marie Barais presented her crossbordering feasibility study. The objective is to determine the feasibility of the Gut Feelings Questionnaire (GFQ) in daily practice in primary care. GPs fill in the GFQ after the first consultation during 8 days consecutives and afterwards a semistructured interview with the GP will be done. The average time of filling out the questionnaire will be estimated by the GP. The disruption of daily routine caused by the GFQ and the additional workload due to the fulfilment of the questionnaire will be assessed with a four point scale. Questions for the interview are: How do you assess the practicality of the questionnaire in your daily practice? Are there defects in the questionnaire? Are there unclear points you would change in the questionnaire? This international EGPRN project will involve GPs in France, Belgium, the Netherlands, Germany and Poland.

The accuracy of the GP’s sense of alarm when confronted with dyspnea and/or thoracic pain. A protocol about this study has already been published in the BMJ open Marie Barais supplied us with more details about the protocol.

Gut Feeling’s transdiciplinarity in detection of children’s serious infections at french paediatric emergency departments : a national consensus. Thomas Pernin and Laurence Baumann explained the aim of this study: does the gut feelings concept exist in french paediatric emergency departments? Do we need new criteria and a specific definition of gut feeling for these specific situations? The study is on-going but there are some first results. Gut feelings seem to be shared by French paediatric emergency physicians. An adapted consensus about this notion in perspective to children with severe infections is needed. A Delphi consensus procedure is currently in process.

The role of intuitive knowledge in diagnostic reasoning of hospital specialists.Nydia van den Brink and Anne Schuurman presented the results of a literature study and a focus group study. The research questions of the first study were:

  • Which role plays intuition in the diagnostic reasoning by hospital specialists?
  • Does the use of intuition collide with the model of EBM within specialist medicine/the hospital?
  • Do different hospital specialists use intuition differently?
  • Does the use of intuition result in medical/diagnostic errors?

The literature search showed that intuition often is used in combination with analytical reasoning. It is not inferior to other kinds of reasoning including EBM but complementary. Experienced doctors use more intuition in the form of pattern recognition. Their intuition is more sensitive and specific than that of less experienced doctors. Intuition is not perfect, because it is prone to errors.

Next they started a focus group study with hostital specialist to find answers on questions such as which type(s) of diagnostic reasoning is (are) used? When does one type of diagnostic reasoning predominate? Are there triggers for a specific type of diagnostic reasoning? What are the effects of a gut-feeling, if present? What’s the validity of different types of diagnostic reasoning?

The analysis of the text of the first group is still on-going.

Gut feelings in diagnostic reasoning: the role of context and experience. In this study, presented by Margje van de Wiel, the research questions were: does manipulation of context influence the diagnostic outcomes? What is the role of contextual triggers? What is the role of experience?.  Sixteen clerks in general practice, 16 first-year GP trainees and 16 experienced GPs diagnosed seperately 6 cases and fill in the gut feeling questionnaire (GFQ) while thinking aloud. The context was manipulated in 2 cases. The analysis is still on-going but the preliminary results are that the context may strongly influence diagnostic reasoning, that gut feelings play a role at all expertise levels and that for these ambiguous cases no expertise effects on diagnostic accuracy could be found.

The Gut Feelings Questionnaire: how do experienced GPs, GP trainees and medical students interpret the items? Erik Stolper presented the results of a study nested in the above mentioned study about gut feelings in diagnostic reasoning (Margje van de Wiel). There were three research questions:

  • Which diagnostic reasoning tracks are followed by experiental GPs, GP trainees and medical students? (RQ-1)
  • Which diagnostic reasoning tracks are followed by these participants when filling in the GFQ? (RQ-2)
  • Are there reasons to adjust the GFQ? (RQ-3)

A systematic content analysis of the first 8 (transcribed) interviews of each group was performed. The 6 case vignettes often appeared to induce feelings of uncertainty in the participants of all three groups. Patterns were mostly not explicitly recognized by the participants. So the case vignettes were difficult for the participants of all three groups. RQ-1: There were minor differences in diagnostic reasoning (DR) between the three groups. The first phase of diagnostic reasoning is mostly and probably an automatic generation of working hypotheses based on matches between symptoms and knowledge. The next phase is a semi-analytical weighing process with mostly intuitive assessments of the power of arguments for or against the likelihood of diagnoses.Arguments are quite often used to reduce uncertainty and anxiety, to overcome uneasy feelings and diagnostic deadlocks. The sense of alarm often seems related to prognostic uncertainty and less to diagnostic uncertainty. Students have the most extended weighing process and seem to show more uncertainty, concern and chaotic thinking. RQ-2 and RQ-3: In general there were no differences in the way the three groups interpreted the GFQ-items. As to item 1, 2, 5 and 10 there were minor problems with the interpretation. A proposal to adust these items was discussed. The different research groups in France, Germany, Belgium and the Netherlands, and in Poland will make a definite decision about the proposed adjustments.

Exploring anticipated regret in diagnostic decision-making. Hypotheses and study design. Norbert Donner-Banzhoff presented an overview of regret in diagnostic decision making. Regret is the feeling that a decision should have been made differently because the actual outcome differs from what has been expected. Anticipated regret:  human beings are often aware of this to occur at the time of their decision-making. They therefore try to avoid, or at least deny or suppress regret (regret regulation), which may thus influence their decision-making. (Zeelenberg&Pieters, 2007) Regret regulation or the anticipation of regret in medicine is often a »pathological« professional reaction with as results: lowering of diagnostic thresholds, a preference for analytical reasoning, a search for more data and more technology, and more “defensive medicine“.

General discussions. After each presentation, there was a vivid discussion between the 25 participants. One of them composed a beautiful one-liner: ‘gut feelings do not stop thinking, on the contrary they do start thinking’. At the end we discussed which issues should determine our future research such as the accuracy of the gut feelings test compared to other tests in general practice. Or should we opt for the process of gut feelings which are changing in time due to objective and subjective reasons and which often lead to a kind of reflection? Or how should we teach gut feelings to medical students?  And what is the relation between gut feelings and anticipated regret in situations of diagnostic uncertainty?

Navigating Clinical Uncertainty

The next two days the COGITA group participated in the 10th workshop on Clinical Decision Making and Diagnostic Reasoning.

All decisions made by physicians, clinical psychologists and other health professionals are fraught with uncertainty. It is uncertainty that drives patients to consult clinicians in the first place. They want to learn about their prognosis, the cause of their problem and possible treatment. Despite scientific evidence being easily available today, all too often there remains uncertainty regarding the fate of an individual patient and whether treatment will do more good than harm. Clinicians have developed strategies to deal with this situation. The terms ‘intuition’, ‘heuristics’, ‘gut feelings’ etc. stand for experiential knowledge that clinicians from all disciplines use in their everyday practice. This kind of knowledge is often contrasted with explicit knowledge backed by scientific evidence. Both ends of the spectrum are necessary for the successful management of patient problems. However, professions must criticially reflect both evidence based and experential strategies for their validity, benefits and possible harms.

Some presentations. Margje van de Wiel was one of the keynote speakers. The title of her presentation was ‘Skilled intuition in becoming a clinical expert’. She gave an overview about definitions of expertise in the literature, knowledge as the origin of the expertise, conditions for intuitive expertise and how to foster the development of expertise. Norbert Donner-Banzhoff, another keynote speaker, gave us a framework for clinician-patient-collaboration using the terms causality, probability and a good story. Stefan Bösner presented ‘Cognitive strategies for primary care diagnosis: the role of inductive foraging, triggered routines and hypothesis testing’. He discerned three strategies ,three kinds of information search to narrow down possible diagnoses: a patient-guided, a routine questioning-guided and a hypotheses-guided information search.