In acute care medicine, we spend considerable time and energy studying diagnostic tests that will aid us in finding that potentially dangerous diagnosis. If we look at the recent literature of patient’s with acute chest pain who present to the emergency department, millions of dollars have been spent on improved diagnostic tests that will improve our ability to determine who had a heart attack (or is at least at risk) and who didn’t.
In medicine, we love facts, we love evidence. We seek abnormal results that will help us explain the patient’s symptoms. Using a complex (but not well understood process) we integrate the patient’s history, the physical examination and then selected tests to help determine whether or not the patient has a serious illness. In general, this process is the formulation of a clinical impression.
More recently, clinicians are being taught about the potential biases that can creep into our clinical judgement and how to prevent or deal with them. Maybe you are more likely to attribute a diagnosis (incorrectly) to a patient if you saw a similar presentation last week. Or maybe fatigue will lead you incorrectly down the wrong path. Or perhaps you’re more likely to attribute a benign diagnosis to a patient because it’s more common and neglect some key aspect of the presentation (e.g burning chest pain MUST be heartburn…).
In general, we as physicians will formulate a clinical impression based on the evidence presented to us. We then develop a pre-test probability and make decisions for appropriate testing afterwards.
Well there’s a fascinating new study in the BMJ that looks at the role of “gut feeling” of physicians in the diagnosis of serious pediatric infections. Interestingly, the authors differentiated “gut feeling” from clinical impression:
- clinical impression was defined as “a subjective observation that the illness was serious on the basis of the history, observation and clinical examination”
- in contrast a gut feeling was defined as “an intuitive feeling that something was wrong even if the clinician was unsure why”
They authors (from Belgium) studied more than 3000 pediatric patients (0-16yrs) who presented to their primary care provider. These physicians were asked to provide an overall “clinical impression” as well as their “gut feeling” about whether a serious infection was present. Among the patient’s who were assessed clinically to not having a serious infection, a gut feeling that there may be something wrong anyways was associated with significant increase risk of serious illness (Likelihood ratio of 25). For the non-statistically inclined, anything about 10 is very predictive! And when the gut feeling was that there was no serious illness, then the probability decreased from 0.2 to 0.1%. This study is fascinating and highlights some potential for educators in curriculum design within medical education. We should not discount our “gut feelings” and likely trainees should be educated in how to manage such feelings. The authors summarize the implications of the study for future training quite nicely:
“Although students and trainees are taught to look at children’s overall appearance and breathing, there seems to be a potential gap between the routine clinical assessment of these features and the more holistic response, producing a “something is wrong” gut feeling. Perhaps we should also be more explicit in encouraging sensitivity to parental concern, stressing that it does make the presence of serious illness more likely even when clinical examination is reassuring. We should certainly make clear when teaching that an inexplicable (or not fully explicable) gut feeling is an important diagnostic sign and a good reason for seeking the opinion of someone with more expertise or scheduling a review of the child.”
Objective To investigate the basis and added value of clinicians’ “gut feeling” that infections in children are more serious than suggested by clinical assessment.
Design Observational study.
Setting Primary care setting, Flanders, Belgium.
Participants Consecutive series of 3890 children and young people aged 0-16 years presenting in primary care.
Main outcome measures Presenting features, clinical assessment, doctors’ intuitive response at first contact with children in primary care, and any subsequent diagnosis of serious infection determined from hospital records.
Results Of the 3369 children and young people assessed clinically as having a non-severe illness, six (0.2%) were subsequently admitted to hospital with a serious infection. Intuition that something was wrong despite the clinical assessment of non-severe illness substantially increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and acting on this gut feeling had the potential to prevent two of the six cases being missed (33%, 95% confidence interval 4.0% to 100%) at a cost of 44 false alarms (1.3%, 95% confidence interval 0.95% to 1.75%). The clinical features most strongly associated with gut feeling were the children’s overall response (drowsiness, no laughing), abnormal breathing, weight loss, and convulsions. The strongest contextual factor was the parents’ concern that the illness was different from their previous experience (odds ratio 36.3, 95% confidence interval 12.3 to 107).
Conclusions A gut feeling about the seriousness of illness in children is an instinctive response by clinicians to the concerns of the parents and the appearance of the children. It should trigger action such as seeking a second opinion or further investigations. The observed association between intuition and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills.