WONCA 2007

“Something does not fit in here!” – Irritation in Clinical Decision Making

Introduction
Clinical decision making physicians construct and routinely access different internal knowledge bases, “facts and figures”, “illness scripts”, “pattern recognition”, and “reflective practice”, combining non-analytic elements (“gut-feeling”) with deliberation to varied extent. Occasionally, an internal sensation of alarm irritates expert GPs while caring for a patient.

Objectives
Define “sensation of alarm” and its elements. Describe triggers, causes and favourable conditions. Understand better its value, limits and reliability for the decision making process and theory.

Methods
9 single-person interviews with German GPs, randomly chosen, have been audio-taped, verbatim transcribed, coded by two researches independently using Grounded Theory, and analyzed for concepts.

Results
GPs gave between two to five personal examples for this sensation in a quick row describing that “something does not fit” in a given clinical situation, and that this flashed off the background of their individual patient’s history knowledge, triggering situational circumstances, or GP’s anticipation which was not met. This phenomenon was co-notated with no, negative or positive emotions, sometimes with strong vegetative reactions. Reflection about physician’s own practice was caused frequently re-directing the further course of clinical encounter.

Summary
GPs established the existence of the phenomenon beyond doubt using the words “Something does not fit in here!” rather uniformly. Nevertheless, they described non-analytical processes in their decision making which differed considerably from each other.

Conclusion
If this phenomenon is a homogeneous entity, remains doubtful and needs further research. Theory of complex dynamic systems illuminates why irritation is essential, to leave routine pattern recognition for reflective practice.

Johannes Hauswaldt