The Australian response to gun violence…less is more

This week, Annals of Internal Medicine published a well written editorial about how Australia has managed to significantly reduce gun violence with a nod to the measures it took back in 1996. It’s unfortunate the physician base within the US hasn’t been more vocal to advocate on behalf of patient safety or even prevention. The attempt to combat gun violence with more guns (and arming more people) doesn’t seem to be working. It would be awesome to see stronger advocacy from a well organized group of physicians who have the ability to exert considerable influence. Until US physicians advocate more vocally, it appears to be an opportunity lost.

 

Patient safety strategies ready for primetime

This week, Annals of Internal Medicine published a critical review for strategies designed to enhance patient safety. The best part, the authors summarized their findings into a 1/2 page table outlining 10 “strongly encouraged” and 12 “encouraged” strategies…this makes  for a quick read! Extremely important for those of us who’s attention spans are so short that we can’t even wait in a line at the grocery store without checking our email twice, posting a tweet and reading the daily news.

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

I really liked this list and I think it’s great to publish  for people to review. You can look at what you’re doing at your own institution and if there are things missing, it provides a basis for advocacy.

It’s interesting that many strategies relate to intensive care medicine. I’m not sure if that’s a function of the interest by intensivists/anesthesists in patient safety, a result of funding bias towards ICU-level patient safety studies or maybe that’s where much of the difference can be made (at least from a mortality perspective). What this list also demonstrates is that there are many areas within primary care, trauma care and emergency care that require attention. 

The authors mention that “pre-operative checklists and anesthesia checklists” are strongly encouraged. I agree! But what about checklists during acute resuscitations? We simply don’t know because the evidence hasn’t been developed yet. Certainly I think this can act as a call to those funding and researching patient safety in acute care medicine . Cliff Reid wrote about the “Resus Room Life Guard” several months ago…we don’t know if this is a good idea or improves patient oriented outcomes because it hasn’t been studied. Though intuitively, it seems like a great idea!

There was also no mention about the importance of adequate discharge follow-up from the ED…some hypothesis generating studies that patients who don’t have great follow-up are at risk. But clearly more studies are needed.

Finally, for those of us interested in simulation, it offers additional support that team training and simulation exercises with a focus on patient safety are worthwhile undertakings. A recent study from demonstrated improved communication and teamwork in a trauma centre following in-situ trauma simulation training. In addition, there appeared to be some patient oriented improvements including improved speed without compromise in critical task completion.

The list of strategies is worth a read…see how you compare and see how your institution compares. If you’re not doing the “strong encouraged” items…its probably worth considering why not? Do you really need to put the femoral line in during the resuscitation or will the 2 large bore IVs suffice until the patient can be properly draped and line insertion done under fully sterile conditions? Do you wash your hands before and after every patient encounter? I know at our hospital we have people in the ED (maybe posing  with acute Percocet insufficiency) or hiding in the shadows…yet…they’re really monitoring our handwashing complicance.   While I have been known to get in arguments with them…they’re actually just trying to implement important patient safety measures.

#patientsafety.

That’s it for now. Feel free to post any thoughts/comments.

Information overload…staying up to date with new medical journal publications

As physicians, some of us love to read the latest journal publication while some of us don’t give a s@#!. Those in the latter category are more than happy to get the information at conferences or journal clubs in due time. There’s nothing wrong with these people…in fact, it could be argued this is a healthier approach than being addicted to your wireless device or computer waiting for the newest publication!

But for those of us who do get turned on by reading then talking about the newest publication the day it comes out “Epub ahead of print”, it can be a daunting task to stay up to date.

In our world where we’re exposed to up to the minute Twitter feeds, blog posts or push notifications, we can easily become overloaded and inundated with how to manage this information. The challenge is particularly difficult with journal publications. I admit, that I really enjoy reading the latest research data and while that doesn’t make me a bad person…it arguably makes me a less attentive husband (one woman’s opinion).

Are there any strategies for improving information intake and staying up to date with recent research? I don’t think this area is well taught in medical school or residency, partly due to the fact it’s a brand new method of information acquistion. Also, it’s rapidly changing with new sites and apps coming all the time.

I follow a few different journal topics including emergency medicine related, critical care, general medicine and medical education. Overall, this probably results in about 15-20 journals per month. I don’t read every article, nor do I read every abstract but I routinely read through table of contents or titles to make sure I’m staying up to date.

I’ve been thinking about this recently and while this post isn’t intended to be comprehensive, it does offer a few strategies that I’ve used to ensure I’m reading the newest evidence (any mention of a product/app below is only because I’ve found them helpful…I take no money from anyone). The following are in no particular order of preference. And if there’s an app or strategy I’m missing, please comment and I’ll add it to the post!

Here we go.

QxMD “Read”: I just started using this app and I really like it and I highly recommend it for any physician trying to keep up with the medical literature. And it’s FREE!  Anyways, it’s a Canadian company that “provides a single place to discover new research, read outstanding topic reviews and search PubMed“. It allows you to sign up through your library Proxy account and access PDFs for any medical journal that your library has available. If your university isn’t supported, email them, I believe they are really working hard to add new institutions. The key component for this app is the user can select which journals they want to receive regular updates from and easily access. Here’s a great review of the product.  For those using Android/non-Mac products I don’t think its available for any other platform than Apple (I only use Mac so I can’t confirm this).

Settings page for "Read"

Settings page for “Read”

Main interface used when reading articles

Main interface used when reading articles

Feedly: I also highly recommend this! and it syncs with GoogleReader which inexplicably is getting shut down. This program provides regular updates to any journal you wish to add to your list. The benefit to this approach is that it syncs well across platforms (both mobile and desktop) and it also houses all of your non-medical blogs and news sites. The difference between Feedly and QxMD is the latter offers a much easier route to read the PDF. Feedly simply provides you with the abstract then its up to you to figure out your own access method.

Screen Shot 2013-04-21 at 11.40.53 AM

Subscribe to a journal’s table of contents (TOC): Most journals allow you to provide your email so that every time a new volume is published, the TOC arrives in your inbox. This is how I started following journals though depending on the number of emails you receive (and the number of journals you follow), this process can easily overwhelm.

Example of "The Lancet" Table of Contents email

Example of “The Lancet” Table of Contents email

Subscribe to programs such as Journal Watch or InfoPOEMs (from Cdn Med Assoc): Essentially these organizations review the literature (typically 1-2 months behind) and send brief summaries of selected articles. This isn’t comprehensive and they’re not always free (e.g. Journal Watch) but it does help you find out about papers that maybe you wouldn’t have read. I use these methods then I download the article myself using my University library account. But it is a bit more labor intensive than Feedly or QxMD.

Follow an up to date medical blog. For those in emergency medicine/critical care, lifeinthefastlane.com is a must. The authors of this blog provide high quality, regular, up to date information about new publications that will interest EM physicians. Sign up to their LITFL review and they outline some of the newest journal articles out there. In addition, they link you up with all the most recent blog posts from around the EM world.

For those interested in medical education – I highly recommend a new blog “Medical Educator 2.0” that compiles medical education (and general education) related topics from sources around the world. Ali Jalali is a medical educator at the University of Ottawa (and happened to be a professor of mine in med school) and he puts together a very high quality site. If you subscribe then you’ll get regular emails when a new version/updates are posted.

Download each journal’s app: Great if you only read 1-2 journals but not sure how useful this is if you’re looking for regular updates from a broad range of journals. Here’s a list of journal apps for download.

Twitter: Either sign up and follow a journal’s twitter account (e.g. @EmergencyMedBMJ) or follow individuals that often retweet or post comments about new articles. This approach really maximizes the power of crowds and can make reviewing new articles much easier. On Twitter, you can also follow hasthtags like #meded and #FOAMed.

So those are a few strategies that I use. I welcome feedback and suggestions that I’ve missed. I’m happy to update this post with any ideas that you feel should be included.

Deception and misdirection – Is being “unethical” a bad thing during medical simulation?

This week’s post was prompted from a recent set of articles in the journal Simulation in Healthcare. Until recently, I’ve given little thought to purposeful deception during  simulation scenarios. Often scenarios are designed to be somewhat “tricky” with a key learning point. This often takes place by incorporating a random medical fact/concept that the learner may not pick up. For example, the seizing patient in refractory status epilepticus…if the participants took a proper history from the family they would have found out that patient has recently started treatment for tuberculosis. The diagnosis of INH induced seizures would be clinched  But what about when you purposefully try to mess with the participants and actually challenge their personality, their ability to behave as a physician and arguably break the psychological safety that should exist within a simulation? Is this beneficial or does such a scenario inhibit learning? optical-illusion-man

I’d like to review and comment on the articles and editorials published in the most recent edition Simulation in Healthcare. The article is a description about how simulation was used to test/study medical hierarchy during a medical resuscitation.

The authors (pediatric intensivists) implemented a scenario where a young child was critically ill with hyperkalemia resulting in a dysrhythmia and incidental hypophosphatemia. The team leader (who was a confederate) was scripted to order potassium phosphate to replace the low phosphate, however, this would also result in death of the simulated patient. The learners (ICU residents/fellows) had some idea that a team leader (staff intensivist) would appear part way through the case but were unaware that such hierarchy conflict would emerge. The team leader confederate was instructed to comply by not administering the drug only if the team demonstrated repeated or sustained challenges in giving this potentially deadly medication. The authors describe running the scenario 3 times and reported the following responses:

  1. Appropriate, successful challenge of drug administration and team leader complied
  2. Appropriate challenge but delayed resulting in delayed appropriate management
  3. The order was not challenged and the simulated patient died

What are you thoughts after reading this? Do you have a visceral reaction that this was a good or bad idea?

My opinion is that in the right circumstances with trained educators I think this is extremely powerful, useful and should be part of the educational toolbox. There’s an accompanying editorial where the authors have raise multiple concerns about this approach which I won’t reiterate – all of which are valid. Though interestingly they also provide well written counter arguments in anticipation of how others may respond.

Simulation scenarios that address non-medical aspects that can lead to patient harm should be simulated. While I agree that this type of case probably is best administered by an experienced simulation educator with highly skilled participants, I disagree with the editorial which suggests that such scenarios should be avoided. They were concerned that this may cause the participant to think:

“Am I the kind of person who is unwilling or unable to challenge a respected colleague who I think is making bad medical judgments, even when this may result in serious injury to the patient, or even death”

I would argue (like the study’s authors) that with proper briefing regarding the educational purpose of the simulation and adequate de-briefing to explore the cognitive decision points that resulted in the patient’s outcome, then learning can be achieved. The degree of deception should be related to experience level of the participants since junior learners would unlikely benefit from such a difficult scenario. However, increasingly, we recognize that teamwork and crew resource management (CRM) play an important role in how we care for patients. Our non-technical skills and awareness to our own cognitive biases during critical situations has considerable impact on patient outcomes.  It’s inevitable that during critical situations we may face challenging interpersonal interactions or difficult decisions.  We should train by pushing the limits of the team and the system. I acknowledge there are some who are concerned regarding the disregard for psychological safety during such simulations. I argue that with proper approaches that psychological safety can be managed. Furthermore we can do a much better job controlling the psychological safety of a simulation than we can simply leaving learners to fend for themselves during a real-life situation where not only their psychological safety is at stake, but the medical safety of the patient is at risk.

The argument that we should study this more before widespread use is reasonable but I’m not sure that results from one centre will be applicable to others. The validity of such studies remains challenging to say the least. Certainly larger studies will help, but meanwhile simulations including misdirections or deceptions that challenge not only technical knowledge but interpersonal and team dynamics should be supported.

 

Abstract from cited article above 

Case & Commentary: Using Simulation to Address Hierarchy Issues During Medical Crises. Calhoun AW et al. Simul Healthc. 2013; 8(1):13-19

Medicine is hierarchical, and both positive and negative effects of this can be exposed and magnified during a crisis. Ideally, hierarchies function in an orderly manner, but when an inappropriate directive is given, the results can be disastrous unless team members are empowered to challenge the order. This article describes a case that uses misdirection and the possibility of simulated ‘‘death’’ to facilitate learning among experienced clinicians about the potentially deadly effects of an unchallenged, inappropriate order. The design of this case, however, raises additional questions regarding both ethics and psychological safety. The ethical concerns that surround the use of misdirection in simulation and the psychological ramifications of incorporating patient death in this context are explored in the commentary. We conclude with a discussion of debriefing strategies that can be used to promote psychological safety during potentially emotionally charged simulations and possible directions for future research. (Sim Healthcare 8:13Y19, 2013)

 

 

 

 

 

 

 

 

 

The time for checklists in medicine…is NOW!

I have written about checklists in medicine before, but in light of a recent publication in the New England Journal of Medicine, I was inspired again to write about it.

One of the leading advocates for checklists in medicine is Atul Gawande. His book “The Checklist Manifesto” is an excellent read for anyone interested in the topic and definitely well written for the lay-person. Notably he’s also the senior author on this randomized trial just published in NEJM. And while the NEJM is often busy publishing some questionably biased and often pharma-funded studies, this one deserves attention. But before I discuss more about the trial…I digress…

Just this week, while we were flying I observed something quite interesting. Typically when we fly in the helicopters, our pilots ask our crewman for landing checks. At which point the crewman will go through the checklist with the pilot answering appropriately. We were out on a job and the crewman was busy in the back of the machine so the pilot read the checklist himself. After each item on the list, the pilot would answer himself….basically talking to himself. I remember asking a pilot about the value of a checklist for both their critical and non-critical procedures. He told me that by doing a checklist, he could concentrate on the variables that may arise and not worry about forgetting something small or routine. This is interesting…

I can’t remember the last time I’ve seen a physician read off a checklist, answering to themselves that all everything required is present and functional.  In medicine, we have this idea that if we can’t remember everything then it’s a sign of weakness. We don’t use checklists. In our minds “checklists are for losers” (not sure who I’m quoting here). But this idea that we must remember everything during a critical event is unique to medicine. Obviously I’m not advocating that we shouldn’t commit anything to memory but why bother trying to remember mundane items when we should be concentrating on “owning the resuscitation” (A term coined by Cliff Reid from resus.me).

We should instead focus on identifying why the patient is crashing or what might make this particular intubation difficult. We should NOT be trying to remember whether we’re missing anything… “ok…so I have the BVM, suction, tube…anything I’m missing? Of course! We need RSI drugs!”…this is a useless conversation and waste of time. By using a checklist the cue for RSI drugs will happen and the focus can be on more important things like ensuring the patient is well positioned, critically evaluating the cause for clinical deterioration – then the clinician can focus on real problem solving.

It’s interesting that many of the HEMS services out there are using RSI checklists and yet few are used in EDs around the world. At our HEMS service, we use it because we work in often hectic conditions that can be quickly become uncontrolled situations with unstable patients…wait a second…that sounds remarkably like an ED around the world! So why not implement a similar protocol? A recent paper in J Trauma looked at a standardized approach to RSI in trauma…seems promising!

And as I mentioned above, the NEJM recently published a large randomized trial evaluating the use of checklists for high-fidelity crisis simulation in an operating room setting. The use of checklists resulted in a 75% reduction to adhere to critical steps in management. Most impressively, the difference in missing critical steps was 6% with checklists vs. 23% without checklists. That’s an absolute reduction of 17%! And a relative risk reduction after multivariate analysis of 28%. If there was ever a drug trial that showed similar results it would likely be put in the water (maybe fluoride?). But last time I checked, no one will be making much money by producing a checklist. And yet despite our inability to show much more than non-inferiority with new oral anti-coagulants (vs. warfarin), the increase in use is HUGE!

This figure below published in the article is impressive. It demonstrates how the same team behaved completely differently depending on the use of a checklist. Some of the instances where they failed to adhere to critical processes of care is unbelievable and certainly is NOT good for patient oriented outcomes! V.fib and no defib for 1.5min? WOW!

Prime example of how checklists can help during resuscitations! Published in NEJM

Prime example of how checklists can help during resuscitations! Published in NEJM

I agree that we should probably study the implementation of a checklist into emergency medicine…but we probably shouldn’t wait longer. Recent publications show adverse event rates (or near misses) of 10% during RSI in the ED. This is NOT acceptable. We can do better and we should do better. Time for checklists to become an integral part of our critical actions. We can assign the checklist to be administered by our resuscitation room safety officer (yes, another novel concept that also deserves consideration…check out Cliff Reid’s great blog post on the topic)

 

Not forgetting what you learned – how we can do better in medical education.

This blog posting was inspired by a tweet by @ARJalali (website: Medical Educator 2.0).

Remember that 10th grade history test? No.

Or that psychology exam in first year university? Probably not.

This propensity to forget what we’re learning has carried through to medicine and it appears that our same study habits that we adopted early in our educational careers really don’t serve us well. Cramming doesn’t work. Well, it does to pass the test but as we move into a field where we need to remember things for more than just a day, we need to have ways to learn better. We need to adopt techniques and integrate within our curricula improved methods for trainees to retain knowledge. You could argue that memorizing is less important with any fact just a “google” keystroke away. I agree. But we still need to retain information as it makes us more efficient during clinical situations, in emergent situations we MUST remember and finally it makes it easier to teach others.

Wouldn't you like a method to remember better, than just a few post-it notes?

Wouldn’t you like a method to remember better, than just a few post-it notes?

Psychologists have been interested in these concepts for decades and several interesting ideas have emerged. “Spaced education” – the idea that educational encounters which are spaced over time and repeated result in improved and more efficient learning. Contrast this to everyone’s favorite “Bolus education” which is found at conferences when you sit down for a 1 hour lecture and you expect to actually remember something. Or sit in front of that textbook for hours before the exam then as soon as you walk out of the exam…surprise…you don’t remember a thing!

A study by a urologist published in 2007, randomized medical students to receive this “spaced education” endeavor. This occurred by regular emails with short clinically relevant questions/scenarios followed by MCQ and a summarized “take-home message”.  There were 4 core topics for the urology curriculum at this medical school and half of the participants received 2 topics by “spaced education” while the other participants received the other 2 topics by space education.

The results? Spaced educational emails significantly improved composite end of year tests. With greater benefit for those who received the emails over a longer period (6-12 months).

Another, similarly designed study found that this could be done with consultants and residents. There were statistically significant improvements across a range of topics when learning included a “spaced education” model followed by testing on a cyclical basis. Most importantly 84% of participants wanted to engage in additional programs!

Brilliant! I love this idea! This is a similar concept that is occurring now doing with Twitter and FOAMed (Free open access medical education). Though spaced education is more formalized and contains an evaluative piece. The concept is the same however…deliver short bits of information to the learner on a regular basis. This will improve retention and their ability to self-assess performance.

Educators can easily utilize Twitter or other forms of social media to deliver a regular stream of information to learners which then ideally integrates an evaluative component. This evaluation part is more than just finding out what the learner knows…it functions as an additional learning tool!

How do you use Twitter in medical education? A new article outlines “how to” tips

This past week I posted my first tweet.

twitter

I feel like an old man writing “how I walked uphill both ways to school in 5ft of snow”. For many of you, I’m sure I sound like I may have just recently adopted electricity and the wheel…but I figured I should join the masses and test out this “new” technology.

I’m not sure what’s taken me so long to move to the Twitterverse but part of me was still trying to figure out its utility. I guess I wasn’t so sure how I could use something such as Twitter…especially since all my entire impression of the technology was that it existed as a bulletin board for the latest celebrity breakups, hookups or feuds. I figured a few episodes of Entertainment Tonight should suffice as a Twitter replacement and I wouldn’t need this new technology…

However, I thought that there must be some way this can be effective within medicine…I’ve come across some physicians in Toronto who’ve started to use it. So before joining I followed along for a little bit to see how they used it. They often tweeted about new articles or cutting edge technologies…it seemed quite up to date and a great way to follow all that was new in medicine!

Then I came across a great article that was just published in Medical Teacher by a few medical educators in Calgary. They summarized 12 Tips for using Twitter in medical education. For anyone who teaches or is involved in medical education I highly recommend reading this paper. It provides practical reasons for Twitter and nicely summarizes how it has been described in the medical literature!

Not trying to steal the thunder of the authors but wanting to share a few of their tips…In the spirit of the wiki mindset which now pervades our consciousness, I’ve posted a few below. Enjoy!

I’ve picked the ones I thought were best and added a few comments or paraphrased the authors.

  1. Use a twitter account for a specific class or group: be sure to set some ground rules so that learners will have a framework for the discussion
  2. Use a live Twitter chat in your next lecture: I’ve been to a few lectures recently where this was done and it’s really quite interesting. What’s especially cool is if people from outside the classroom tweet a comment! The beauty is that they can be anywhere else in the world. If you’re using it for questions, it might be best to only open it up near the end of the lecture or at least only post it on the projector during a dedicated time as it may serve as distraction rather than an effective tool.
  3. Tweet key resources or new literature for your students to use and read: This is an excellent way to flip the classroom. Have them follow along and get them the material before class so that they can read it, digest it then come to class or academic day and discuss & analyze it. Or simply provide a resource for them to access the latest articles that you’re reading.
  4. Use twitter for real-time feedback: If you can make it anonymous this could be pretty cool. It could be posted in real-time at the end of the lecture or course. Though the logistics of creating anonymous usernames may limit its utility…unless they’re ok with identifiable responses.
  5. Maximize the power of Twitter with emphasis efficient communication: Twitter’s benefits include having only 140 characters to post high yield information. Use this to your advantage in teaching your students concise summaries for case presentations, etc…
  6. Twitter as a tool for self & group reflection:  I love this idea. I think it presents a novel way to gather feedback and one which many learners are comfortable using.
  7. Informal polls & quizzes: I think this is a good option though there may be a better app out there called Socrative which I’ve blogged about previously.
  8. Use it as subject for further study: There’s little out there regarding this topic and could be an outstanding resident research project! I definitely agree with the authors that further study is needed. Most importantly the authors specifically state that valuable studies would not compare Twitter to no intervention but rather evaluate how best to integrate this powerful technology.

I’m looking forward to seeing Twitter become increasingly used and studied within medical education! How will you use it?

Source: SE Forgie et al. Twelve tips for using Twitter as a learning tool in medical education. Medical Teacher 2012 [Epub ahead of print]

What’s the value of a “gut feeling” in medicine? Maybe alot!

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. gutfeeling

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.” 

Van den Bruel et al. Clinicians’ gut feeling about serious infections in children: observational study. BMJ 2012; 345:e6144.
STUDY ABSTRACT  

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.