Report on a meeting of the ‘Gut Feelings in General Practice’ research group Maastricht-Antwerp with 9 leading general practice medicine researchers from Flanders and the Netherlands

7 November 2013

The letter inviting researchers to this meeting described its purpose as follows: ‘At this stage, the further progress of our “Gut Feelings in General Practice” research project requires making certain choices and further developing  the options chosen. To this end, we would like to call on your expertise. We would like to discuss with you and other experts question such as how best to present our “Gut Feelings Questionnaire” to the international community of general practice medicine researchers: what designs would appear to be feasible using the questionnaire, how can we tie in with existing clinical research, and what options are available to set up quantitative research at European level? We would appreciate your help based on your specific expertise.’

The meeting

Attending: Jos Kleijnen, Patrick Bossuyt, Samuel Coenen, Luc Debaene, Stefan Heytens, Rudi Bruyninckx, Dirk Avonts, Nettie Blankenstein, Wim Opstelten, Geert Jan Dinant, Paul Van Royen (chair), Margje van de Wiel and Erik Stolper.

The meeting started with a PowerPoint presentation outlining the basic elements of the research project, as well as the results achieved so far, the process of validating the gut feelings questionnaire, and an analysis of strengths and weaknesses of the project. The interactive presentation immediately led to a lively debate.

The central theme of the afternoon was to define useful, interesting and relevant diagnostic and educational research questions, with corresponding feasible designs using the questionnaire, tying in with existing or emerging projects at national and international level.

After the presentation, the participants briefly introduced themselves, and were given the opportunity to report any options that would complement their own research. In a second round, the meeting discussed new research options and the major choices that will have to be made. The third and final round was used to identify opportunities for collaboration and to evaluate the outcomes of the meeting. The meeting was rounded off by an excellent ‘Gut Feelings dinner’.

The first and second round discussions yielded a number of topics and comments:

• Uncertainty. The use of gut feelings is based on knowledge and experience and is related to the degree of uncertainty or lack of safety and to risk estimates. The use of gut feelings is not limited to the medical domain. It would be useful to find out how the concept of uncertainty has been addressed in other domains.
• Other disciplines. Gut feelings must surely play a role in other disciplines as well, though they might be referred to by different names. It would be useful to participate in research groups in other domains, such as experimental psychology, as a lot might be learned from that. For example, researchers in Ghent have examined the relation between errors resulting from tunnel-vision and personality traits.
• Knowledge and education: students tend to possess little knowledge, and this may easily lead to feelings of uncertainty. They should be taught to deal with this uncertainty, become aware of gut feelings and use these feelings appropriately in the diagnostic process.
• Assessment timing. The questionnaire assesses the GP’s final feelings, i.e. at the end of the consultation. On the other hand, gut feelings is a dynamic concept, so would it not be better to choose a different assessment moment? After some discussion, the meeting concluded that the final gut feeling at the end of the consultation is the best moment to apply the questionnaire.
• Not extending it too far. It is not useful to ask in each and every case whether there is a sense of reassurance or a sense of alarm or whether gut feelings are not applicable. Follow-up studies should be limited to a particular segment of diagnoses for which gut feelings are relevant. It is not useful to further analyse a sense of reassurance if the diagnosis is very clear. Have another look at the findings of the prevalence study (2005): what ICPC codes are most frequently mentioned in cases where there is a sense of alarm?
• Research into cues. There are always cues that induce a sense of alarm, but have those cues been ignored? Or are relevant cues focused on later as a result of the sense of alarm? It is a circular process, and this must be incorporated in the design of follow-up studies. Can the complexity science model be of service? The significance of cues is context-dependent!
• Relevance to society. Examine the relevance to society of the use of gut feelings. The national triage system used by the Dutch College of General Practitioners attaches a clear value to a sense of alarm (ES: and the same is true for the child maltreatment protocol). This relevance to society should be made more explicit and should be mentioned in research grant applications.
• Protocols. Can the research findings not be used in formulating protocols and guidelines?
• Language. Language enables subconscious processes to be explicitly researched.  Medical decision theory – especially the Diagnostic Logic educational model developed in Antwerp – uses specific verbal concepts that make the diagnostic thought process manageable. An explanation was given of the model of a mixing console with various sliders linked to information channels and thought processes.
• Out of the ordinary. The perception by patients or GPs of something being unusual or ‘out of the ordinary’ can be regarded as an operationalization of the sense of alarm. This expression could be used as a parallel question to item 10 of the questionnaire, and be incorporated in follow-up research.
• Names. Names of relevant people that were mentioned included Gerd Gigerenzer and Henk de Vries (professor at the Academic Medical Center in Amsterdam, who collaborates with Nettie Blankenstein and intends to study tutorial dialogues).

The final round of the meeting was used to summarise what had been discussed; a few general principles have emerged:

The Gut Feelings research group could move in two different directions. On the one hand it could focus on theoretical research into the exact nature of the gut feelings that emerge in a doctor’s brain, e.g. through psychological research. On the other hand, it would at this point in time seem more relevant to move along more practical lines, i.e. to improve the decision-making process by utilising gut feelings. This could yield learning experiences that might be relevant to society as they lead to better diagnostic management.

• Clinical reasoning. Gut feelings are a normal part of diagnostic reasoning, as well as of the process of learning diagnostic reasoning, so research should focus on this. It might be useful to record GP consultations and analyse them, first with the doctor, immediately after the end of the consultation, and later with others, including experienced GPs or students.
• Making / avoiding errors. What role do gut feelings play in making or avoiding errors in diagnostic management? This is a topic that is relevant to society and ties in with the topic of safety in care provision. Researchers should try to investigate this both in their own practice and at out-of-hours medical services.

Decisions. It was decided that a report on the meeting would be sent to all participants. It might be a good idea to invite the same group once more in a year’s time to see where we stand then. The participants will take all the information along to their own research groups, and will look for opportunities to collaborate. Any researchers elsewhere who would like to participate in the Gut Feelings research group are welcome to do so.