“Something doesn’t fit, here!” – Sensation of Alarm in Clinical Decision Making

EGPRN meeting at Nijmegen (2007)

Background:
In clinical decision making, physicians combine non-analytic elements (“gut-feeling”) with deliberation. Occasionally, GPs observe an internal sensation of alarm when caring for patients. A discrepancy realised in comparison with a previous encounter has been described as one of GPs’ most important diagnostic instruments.

Research questions:
To define “sensation of alarm” and its elements. To describe triggers, causes and favourable conditions. To understand better its value, limits and reliability for the decision making process.

Methods:
9 single-person interviews with German GPs have been audio-taped, verbatim transcribed, coded by two researches independently using Grounded theory, and analysed for concepts.

Results:
On little or no prompting, GPs gave between two to five personal examples for this feeling in a quick row. Quite uniformly GPs described that “something does not fit” in a given clinical situation, and that this flashed off the background of their individual knowledge of patient’s
history, of triggering situational circumstances, or of GP’s anticipation which was not met. Several GPs reported no or positive emotions co-notated with this sensation and took it as a turning point for re-directing the further course of clinical encounter. Others experienced negative emotions and strong vegetative reactions, along with self-doubt. Reflection on physician’s own practice was triggered frequently.

Summary:
The existence of a “sensation of alarm” has been established beyond doubt. GPs used the words “Something does not fit, here!” quite uniformly. Nevertheless, they described non-analytical processes in their decision making which were quite different from each other. Emotional and vegetative connotations differ considerably for physician and situation, also.

Conclusion:
If this sensation is a homogeneous entity, remains doubtful and needs further research, as well as its emotional and vegetative connotations.
To alert junior doctors for this “sensation of alarm” during their self-reflection should be introduced into medical education.

Hauswaldt J, Kruschinski C, Hummers-Pradier E