May 17-18th

Future of COGITA: The last years, several times we discussed the future of the COGITA network. It is 10 yrs ago that the network has been established, in Budapest. Our European network becomes every year larger and on the annual meetings members present results of nice studies. We have done a lot of work with some beautiful results such as the Feasibility Study, the linguistic validation procedure of translating the GFQ into 3 other languages and the glossary project. However, we have to make next, more strategic steps, in order to reach a higher level of collaboration, with more active members and a common research project, funded with perhaps European money. Perhaps a new way of stimulating research on our topic is to have a full day of discussing about research ideas how to use the GFQ in an European study, performed in different countries, and by engaged colleagues. Or about writing an expert paper focussed on the intuitive parts of diagnostic reasoning or/and about composing a research agenda. Anyway, we need money to pay this project, the travel costs of the participants and perhaps a small starting budget for a first cross-border study. We discussed ideas such as making a COST proposal (European funds for networking), asking the EGPRN for funds and inviting authors of articles describing topics that are closely related to our subject. In autumn, we will make a plan about how to continue. Perhaps we can organise a first meeting om this topic in Antwerp when Marie Barais will defend her PhD.

The feasibility study: the study is rounded off and a paper about it is submitted.

The thoracic pain and dyspnoea study: Marie presented the main results of the study which has been finished. A question is why in 19 cases GPs have false negative gut feelings –there was not a sense of alarm although the final outcome was still a life-threatening disease. Another question was why not analyse the numbers of the sense of reassurance because they are available.

The hospital specialist gut feelings study: a manuscript describing this study has already been submitted. We changed our experiences with the hospital specialists’ view on gut feelings in diagnostic reasoning, in different countries. Every specialist uses gut feelings in diagnostic reasoning but depending to which country how much reserved they are to admit it.

The child abuse study: After the presentation of the first results, we discussed several questions. In medicine, the frame of reference in the process of arising gut feelings is clear; it is about signs and symptoms belonging to some diseases. However, in child abuse that frame much more depends upon the particular and cultural accepted norms of the GP him/herself about what is good parenting, how do parents need to behave for a happy youth of their children, about sufficient qualities and skills to raise children in such a way that they do not meet the criteria in the definition of child abuse. When it is about sexual abuse or physical violence or even in the case of fighting parents in the presence of their children the frame of reference is much more related to physical signs and so more medical, but in the remained 80% of emotional abuse it is more complicated. That might partly explain why GPs sometimes doubt about following their gut feelings. Anyway, in general, gut feelings are acting when it is about child abuse and make GPs suspicious of what is perhaps going wrong. But they keep struggling with different –sometimes moral- values due to a very broad definition of child abuse, appropriate for worldwide use.

The gut feelings of patients study: we lacked enough time to present the whole study but discussed the final results. It seemed very relevant in the light of a recent diagnostic failure of a French triagiste/secretary. How professional triagistes should be, how well-educated?

Common meeting with CDM workshop:

• Norbert Donner-Banzhoff introduced a flowchart to evaluate diagnostic errors. Did I commit a diagnostic error? Should I have acted differently? Is it a real error or a pseudo error? The answer might be: can you formulate a specific, plausible and realistic rule to prevent a negative outcome? If not it is a pseudo error. We discussed amongst others the rule ‘listen always to your patient’.
• Bernardino Oliva Fanlo presented a literature review about the use of gut feelings in diagnosing cancer.
• There was a presentation about slowing down of the diagnostic reasoning process of radiologists, triggered by unplanned, situationally and responsive initiators.
• There was a presentation about how clinicians frame their observations (the symptoms of the patient) in order to get a -for them sufficient and satisfying- causal coherence that lead to a DSM diagnosis or that just avoid a DSM diagnosis.
• Ulricke Schuck presented her search in the data bank of the medical disciplinary courts in the Netherlands to explore how these courts deal with gut feelings of patients. In further discussions, we might more cleary state that our conclusion that the courts value a patient’s gut feeling positively is not based on the outcome of a calculation. Many patients have some kind of worries when visiting a physician, but often not based on reality. From all those patients only a very small part is complaining afterwards about their physician and only a very small part of those complaints is considered by a medical disciplinary court. In fact, we studied how courts are thinking about the significance of a patient’s gut feeling and found that they consider it belonging to the professional standard to take them seriously, both for communication reasons and for medical reasons.
• Gooske Douw presented an overview of a PhD study about the worry of nurses as a tool to prevent deterioration of a patient’s health situation. She gave words to a nurse worry based on a review of the literature and showed that this worry counts in hospital situation. A question was whether the outcome, referring to an ICU, was independently measured from the reference test.
• Wolfgang Gaissmaier presented an adaptive toolbox for diagnostic decision making. He considered 2 situations, one of risk ( a lot of data, in a high predictable but complex world) or one of uncertainty in an unstable, rather simple world with few data and where probabilities are unknown. We first need to choose in which world we have to make a decision. In the case of risk we need numbers and calculations but in a situation of uncertainty we need gut feelings and heuristics and then is it better to ignore some parts of information. He showed that the wisdom of a group can help to avoid errors and to make better decisions.
• Chiara Lambrechts and Melanie Mees presented a study about the role of intuition in deciding to perform a secondary caesarean section during labour. They performed 8 focus group discussions with gynaecologists, trainees and midwives separately and did an observational study in real practice. Afterwards we discussed with them about the possibilities of a next study, perhaps using the GFQ.
• In the end, Margje van de Wiel and Erik Stolper led a plenary discussion about EBM in clinical practice after giving an introduction about the history of EBM and all criticism.