Margaretha W. J. van de Wiel

Background: GPs consider their gut feelings a valuable tool in clinical reasoning. Research suggests patients’ gut feelings may be a useful contribution to that process. Describing these feelings more precisely could improve primary care professionals’ (PCPs) recognition of patients’ gut feelings and insight into the underlying reasons. These descriptions would also enable a thorough examination of the validity of patients’ gut feelings and their contribution to professionals’ clinical reasoning.Aim: To gather the words and phrases that patients or their relatives use to share their gut feelings with primary care professionals and what they convey and imply.Design and setting: Qualitative study of Dutch and Belgian patients visiting an out-of-hours GP service or a GP’s office.Method: Face-to-face semi-structured interviews were carried out with 47 patients. Interviews were coded using a descriptive content analysis in an iterative process until data sufficiency.Results: Patients or their relatives expressed their gut feelings by using words relating to trusting or not trusting the situation, or to changes in normal patterns. Their gut feelings are most often felt as a sense of alarm. In general, patients experiencing a sense of alarm, particularly mothers of sick children, were convinced that something was wrong and had often learned to trust their gut feeling. A gut feeling was the main reason to contact a PCP. Patients generally felt that their gut feelings were taken seriously.Conclusion: The findings of this study provide an insight into how patients and relatives may express their gut feelings about their own or their relative’s health and how they share these feelings with healthcare professionals. This may help clinicians improve their recognition of patients’ gut feelings, being particularly alert to a patient or relative using phrases that relate to feelings of not trusting a situation, things seeming wrong or different from normal, and experiencing a sense of alarm. Further research should be carried out into the validity of patients’ gut feelings.

Background: Family physicians’ diagnostic gut feelings have proved to be valuable. But what about patients’ gut feelings? Research has shown that patients’ gut feelings may contribute to their physicians’ clinical reasoning. Dutch medical tribunals consider patients’ worry useful for doctors’ diagnostic process. However, how general practitioners and other primary care professionals recognize gut feelings of patients and deal with them in their decision making is yet unclear. We aim to explore how primary care professionals perceive patients’ gut feelings and use this information in their decision-making. Methods: We interviewed 30 Dutch and Belgian primary care professionals, exploring how they recognize and value patients’ gut feelings. We coded all interviews using a descriptive content analysis in an iterative process. Data sufficiency was achieved. Results: Primary care professionals acknowledged gut feelings in their patients, and most participants found them a useful source of information. Patients’ gut feelings might alert them to possible hidden problems and might provide quicker insight into patients’ perceptions. Primary care professionals listed a whole series of wordings relating to trusting or distrusting the situation or to any changes in normal patterns. A patient’s gut feeling was often a reason for the professionals to explore patients’ worries and to reconsider their own clinical reasoning. Conclusions: Primary care professionals regularly considered patients’ gut feelings useful, as they might contribute to their clinical reasoning and to a deeper understanding of the patient’s problem. The next step could be to ask patients themselves about their gut feelings and explore their diagnostic value.

Examining expertise using interviews and verbal protocols

Context: Medical experts have access to elaborate and integrated knowledge networks consisting of biomedical and clinical knowledge. These coherent knowledge networks enable them to generate more accurate diagnoses in a shorter time. However, students' knowledge networks are less organised and students have difficulties linking theory and practice and transferring acquired knowledge. Therefore we wanted to explore the development and transfer of knowledge of third‐year preclinical students on a problem‐based learning (PBL) course with real patient contacts. Methods: Before and after a 10‐week PBL course with real patients, third‐year medical students were asked to think out loud while diagnosing four types of paper patient problems (two course cases and two transfer cases), and explain the underlying pathophysiological mechanisms of the patient features. Diagnostic accuracy and time needed to think through the cases were measured. The think‐aloud protocols were transcribed verbatim and different types of knowledge were coded and quantitatively analysed. The written pathophysiological explanations were translated into networks of concepts. Both the concepts and the links between concepts in students' networks were compared to model networks. Results: Over the course diagnostic accuracy increased, case‐processing time decreased, and students used less biomedical and clinical knowledge during diagnostic reasoning. The quality of the pathophysiological explanations increased: the students used more concepts, especially more model concepts, and they used fewer wrong concepts and links. The findings differed across course and transfer cases. The effects were generally less strong for transfer cases. Conclusions: Students' improved diagnostic accuracy and the improved quality of their knowledge networks suggest that integration of biomedical and clinical knowledge took place during a 10‐week course. The differences between course and transfer cases demonstrate that transfer is complex and time‐consuming. We therefore suggest offering students many varied patient contacts with the same underlying pathophysiological mechanism and encouraging students to link biomedical and clinical knowledge.

Diagnostic reasoning is considered to be based on the interaction between analytical and non-analytical cognitive processes. Gut feelings, a specific form of non-analytical reasoning, play a substantial role in diagnostic reasoning by general practitioners (GPs) and may activate analytical reasoning. In GP traineeships in the Netherlands, trainees mostly see patients alone but regularly consult with their supervisors to discuss patients and problems, receive feedback, and improve their competencies. In the present study, we examined the discussions of supervisors and their trainees about diagnostic reasoning in these so-called tutorial dialogues and how gut feelings feature in these discussions. 17 tutorial dialogues focussing on diagnostic reasoning were video-recorded and transcribed and the protocols were analysed using a detailed bottom-up and iterative content analysis and coding procedure. The dialogues were segmented into quotes. Each quote received a content code and a participant code. The number of words per code was used as a unit of analysis to quantitatively compare the contributions to the dialogues made by supervisors and trainees, and the attention given to different topics. The dialogues were usually analytical reflections on a trainee’s diagnostic reasoning. A hypothetico-deductive strategy was often used, by listing differential diagnoses and discussing what information guided the reasoning process and might confirm or exclude provisional hypotheses. Gut feelings were discussed in seven dialogues. They were used as a tool in diagnostic reasoning, inducing analytical reflection, sometimes on the entire diagnostic reasoning process. The emphasis in these tutorial dialogues was on analytical components of diagnostic reasoning. Discussing gut feelings in tutorial dialogues seems to be a good educational method to familiarize trainees with non-analytical reasoning. Supervisors need specialised knowledge about these aspects of diagnostic reasoning and how to deal with them in medical education.