Short report Cogita meeting in Antwerp

17 October 2012

Participants: Paul Van Royen (B), Marie Barais (F), Geert Jan Dinant (NL), Teresa Pawlikowska (UK), Margje van de Wiel (NL), Laurence Coblentz-Baumann (F), Johannes Hauswaldt (D), Erik Stolper (NL), Stephanie Van Droogenbroeck (B), Rudi Bruininckx (B), Slawomir Czachowski PL), Agnieszka Sowinska (PL), Anja Westram (D), Maria Vogelmeier (D), Norbert Donner-Banzhoff (D).

Four research topics and their (preliminary) results have been presented and there was a discussion about the first concept of a glossary.

1) Johannes Hauswaldt studied Luc Ciompi’s affect-logic and gave an overview of his concept. Ciompi tried to overcome the System 1 / System 2 separation in decision making and wrote a book ‘Die emotionalen Grundlagen der Denkens. Entwurf einer fraktalen Affectlogik’ (1999). In his view affect is a kind of informal logic and he discerned 5 categories of affect: Alltags-Logik (e.g. appetite), Wut-Logik (anger), Angst-Logik (fear), Trauer-Logik (grief) and Freude-Logik (fun, joy). These affects are the fundamental operators of cognitive functions and can be considered as the ‘glue’ or the ‘connecting tissue’ of the human feeling and thinking, intending, deciding and action process. Kahnemann’s concept of thinking and reasoning discerns two interacting systems, analytical reasoning and non-analytical reasoning. The third track model of the Maastricht-Antwerp group used Kahnemann’s ideas but conceptualized gut feelings as a third track in diagnostic reasoning next to medical decision-making and medical problem-solving. Gut feelings are associated with two kinds of affect, a bad feeling (sense of alarm) or a good feeling (sense of reassurance).

2) Slawek Czachowski and Agnieszka Sowinska presented the first results of the linguistic validation of the Gut Feelings Questionnaire (English to Polish). They have followed the linguistic validation procedures including forward-backward translations and have met the international criteria. The Polish way of speaking is more formal and induced the authors to change some expressions. We discussed that a good translation has not only to take in account the linguistic and cultural differences but also the basic concept of gut feelings described in the third track model. Teresa Pawlikowska and the both authors will work together to finalize the definite translation following a similar procedure as the Maastricht-Antwerp group did when they translated the Dutch version into a British-English version.

3) Erik Stolper presented in behalf of the Maastricht-Antwerp group the first results of a study ‘Analytical and non-analytical reasoning in tutorial dialogues and the use of knowledge’. A tutorial dialogue (TD) is a one-to-one teaching dialogue between a GP trainer and a GP trainee. 17 TD were included focussed on diagnostic reasoning.

The research questions were: what is the structure of a TD? How are analytical reasoning and non-analytical reasoning presented in the TD? And how is the use of knowledge?

The conclusions were:

• TDs: danger of artificial constructions of diagnostic reasoning and missing the contribution of NAR.
• GF are prototypical for GF. Discussing GF seems a good educational method to familiarize trainees with NAR.
• Discussing GF may start reflection on diagnostic reasoning in general.
• Contextualizing is a vital feature of general practice and could be taught.
• Elaborated knowledge about diagnostic reasoning is extremely important for GP trainers.

The discussion was about the mixed method approach and the possibility that discussions about gut feelings in TDs could also occur in TDs not focussed on diagnostic reasoning but e.g. on management aspects.

4) Norbert Donner-Banzhoff, Anja Westram and Maria Vogelmeier presented Cognitive Processes in General Practice. It was a big study and the analysis is still going on but there are already some results. They wanted to use the present group as a kind of a focus group discussing the concept of smart induction. The authors presented their study design, the course, the method and instruments and the challenges. We discussed many aspects of the study such like the semi-structured interview versus thinking-aloud protocol, the interpretation of the GP’s answers when they were asked for their first impression, the development of the coding system etc. The 280 encounters with interviews were reduced to 180 cases. After further selection 20 cases will be studied precisely. We also had a debate about the 9 foraging strategy’s.

5)      The Glossary:

• The title of the glossary should be ‘Glossary of diagnostic reasoning’.
• The purpose is to publish on our site a list of terms around diagnostic reasoning but specifically related to the research topics of the COGITA group. Composing the list will be an on-going process. The list at hand should be revised: a uniform format and a short description of the terms with the possibility to click-on for more information. We decided to extend the list with some terms of the probability domain of decision making and to ask all authors to revise their contribution. At the end of this procedure the revised glossary will be send to all COGITA members for comment and agreement. The list then will be published at the public part of the gutfeelingsingeneralpractice.eu site.

Next meeting will be on Malta, 23 October 2013 (and perhaps also 24 October morning), just before the EGPRN congress.

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Short report of the Cogita-meeting October 2011

Current research projects

Marburg group: video recording of 300 GP consultations and interviews afterwards.

Warwick group: analysing 100 consultations using the patient enablement instrument.

Brest group: working on a PhD protocol; sense of alarm in emergency situations.

Maastricht/Antwerp group:validation of the questionnaire finished; analysing tutorials on clinical reasoning (analytical and non-analytical reasoning); the interaction of gut feelings (GF) and other elements of clinical reasoning; studying the GF’s determinant experience; initiating GF research in the hospital specialist domains.

Presentations

• Malin Andre: ‘GPs’ medical decision-making: perceiving the patient
  as a person or a disease’. A prospective and descriptive study with a questionnaire and 16 GPs on 25 consecutive consultations. Immediate problem-solving was most frequent in somatic problems with weight on symptoms, and in psychosocial problems with weight on person. GPs seem to immediately recognize both, problems and persons. which describes expert skills of the GP.
• Teresa Pawlikowska:‘The doctor’s perspective on enabling medical consultations’. In enabling consultations, doctors do consultations with informed flexibility achieved by
  integrating their knowledge of the patient, the taxonomy of the patient’s agenda and key relational elements: trust, recognition, communication, prescribing, and time.
• Norbert Donner-Banzhoff: ‘A mathematical theory of general practice’. “Entropy is a  function of probability, measured in bits per symbol (Shannon). NDB stated that GPs are reducing uncertainty and establishing order by reducing entropy asking some specific questions, and then at a later point of consultation may refer to the specialist, who then continues with a rather ‘simple’ situation.
• Amelie Calvez: ‘GPs’ decisional criteria in emergency and the gut feelings’ place’. Observational study 2010, place: emergency and ICU Quimper hospital, Brittany. A sense of alarm occurs if there is a lack of objective criteria or there are conflicting objective criteria. Analysis of relationship between ‘stroke cases’ with and without a sense of alarm, measured and outlied in a dendrogram, failed to isolate the gut feeling cases from the others.GPs seem to switch from automatical mode into attentional mode, triggered by a sense of alarm.
• Marie Barais: reporting on several outcomes from the ‘Brest Team 2010 – 2011’. In risky environments, a sense of alarm may function as an error prevention tool. It is about systems and humans: decreasing risks by adapting systems and humans to each other.
• Johannes Hauswaldt: “Translating ‘Hier stimmt ‘was nicht’”. Translating this phrase into English with „Something is wrong“ seems not appropriate as there may be a moral connotation with „wrong“.
• Erik Stolper:‘Teaching analytic and non-analytic diagnostic reasoning in instructional dialogues in general practice’. Most of the tutorials were about management and about therapeutic approach, not about diagnostic/clinical reasoning. Found content codes (11 categories, 77 codes) and conversation codes (4 /28). There were elements of generalisation and of individualisation. Impression that In GP traineeship the emphasis is more on the individualisation compared to the general medical education.

Research ideas for future

• Linguistic validation of questionnaire in other languages and using it for further research.
• Research with case vignettes.
• Composing a narrative review on the topic.
• The use of the ‘same’ standardized patients in cross-bordering and comparative research.
• Composing a glossary of terms in the gut feelings research domain and publish it as a COGITA article (a position statement).
• Write down how we approach our field of research and publish the manuscript as a COGITA article (a position statement).
• Search for common background and cultural differences.
• Go on with yearly meetings,sharing ideas and results. Maybe, we need a symposium to present us on a better way. 
• Not only concentrating on GPs but also on other physicians.

Next meeting: 17th and 18th October 2012 in Antwerp.

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 Short report of the Cogita-meeting October 2010

Current research projects

Maastricht/Antwerp group: Investigation into how non-analytical aspects of diagnostic reasoning are being trained in GP training programs, identify obvious gaps and design ways to fill such gaps, using a mixture of qualitative and quantitative research methods. The aim of this research is to improve the quality of GP training programs in order to strengthen the diagnostic competence of young GPs. A gut feelings questionnaire has recently been validated using 16 case vignettes.

Marburg group: ongoing research, with real-life consultations which are video-taped, questions to the GP afterwards and also consisting of a think-aloud-protocol of the GP. Research is done in cooperation with the Gigerenzer group at Max-Planck-Institut, Berlin. Data collection is done in and around Marburg. Results are reflected back to a focus group.

Hannover group: Report of results of 9 in-depth interviews with German GPs concerning the sense of alarm is in process.

Presentations

Gut feelings as a third track in diagnostic reasoning (Margje van de Wiel, Erik Stolper): a theoretical framework to understand how gut feelings arise and function in the diagnostic reasoning process of GPs.

‘Just listen’ (Norbert Donner-Banzhoff): a model of the diagnostic process as walking on a ridge, steep in the beginning and flat further on, to the left the self limiting disease, to the right life threatening conditions, where a “red flag” would make the GP to slide to discriminate for the right.

A European research agenda on gut feelings in general practice (Erik Stolper, Paul Van Royen): ten research questions and nine corresponding appropriate designs on four topics, i.e. the diagnostic value of ‘gut feelings’, the validation of its determinants, the opportunities for integrating ‘gut feelings’ in medical education and a rest group.

The Breizh (Brest) group (Marie Barais, Pierre Barraine and GP-trainees): key partners Telecom Bretagne LUSSI, Centre de Simulation (CESIM), College des Hautes Etudes Médicales (CHEM). Project with Delphi consensus procedures, bibliographic work, vignettes, gut feelings and serious pathologies, how do GPs build their suspicion of pulmonary embolism.

Future programs

Using the gut feelings questionnaire in other countries: linguistic and psychometric validation necessary. Perhaps, the Dutch case vignettes are useful.

Translation of the Dutch consensus statements on gut feelings into German. Delphi consensus procedure in Germany. Reports of the gut feelings research in Europe for the German academic public.

Research into existing video tapes of consultations in general practice.

The website: a literature&refererences and a glossary will be added. Via the share point all Cogita-members will have the possibility to share information, to discuss major items and to build up a data base of relevant literature.

PhD students: Marie Barais, Pierre Barraine.

Preparing of EU-funding applications.