Objective
Dealing with uncertainty is an important part of the decision-making process of general practitioners (GPs). Research shows GPs think ‘gut feelings’ are a relevant phenomenon in the context of this decision-making process. A questionnaire was developed to determine the presence or absence of gut feelings in diagnostic reasoning. Chest pain and shortness of breath are 2 complaints where the decision-making process can be complicated by uncertainty. These complaints can be caused by trivial pathologies or they can be an indication of a serious or life-threatening condition. It is therefore interesting to determine the role of gut feelings in these complaints.
Research question
This study aims to determine the diagnostic value of GPs’ gut feelings in patients with chest pain or dyspnoea.
Design and settings
A prospective observational multicentre study was executed in general practice. Any patient over 18 years old, excluding palliative patients and patients with known coronary heart disease, who visited a general practitioner over a period of 3 months with complaints of chest pain and/or shortness of breath, were included. Participating GPs were then instructed to complete the validated gut feelings questionnaire just after the consultation, and this result was correlated with the severity of the patient’s final diagnosis 4 weeks after this consultation. This study was based on the doctoral research previously conducted in France by Marie Barais et al., which also investigated the diagnostic value of gut feelings in patients with chest pain and/or shortness of breath (1).
Results
A total of 15 GPs from 8 different general practices participated, with a total of 97 completed questionnaires over a 3-month period. Thirty-three questionnaires showed a sense of alarm (34%) and 64 showed a sense of reassurance (66%). Twenty patients were found to have a potentially life-threatening diagnosis after 4 weeks (21%). The positive likelihood ratio was 4.09 and the negative likelihood ratio was 0.19. This leads to a diagnostic odds ratio of 4.09 (95%-CI: 5,63-82,94). The sensitivity of the sense of alarm turned out to be 0.85 and the specificity 0.79. The diagnostic accuracy was 0.80. The difference between the positive likelihood ratios when the results were analysed separately for dyspnoea and for chest pain was insignificant.
Conclusions
We can conclude that gut feelings can play an important role in the diagnostic process of the GP when confronted with chest pain and/or shortness of breath. The likelihood of a life-threatening illness increased from 20% to 50.3% in the presence of a sense of alarm and decreased to 4.5% in the presence of a sense of reassurance. This means that a sense of alarm increases the probability of the disease, it can exceed an (intuitive) action threshold, which makes it unjustifiable to take no further action. In diseases with a low probability, the sense of alarm will not always be sufficient to reach the action threshold, however, it should prompt more detailed clinical reasoning. With gut feelings a further analytical process should be prompted to find out on what triggered this feeling. Teaching GPs to be aware of the presence of this feeling could improve their diagnostic process. Further research could be done to see how this is best handled in practice, for example in the training of GPs. If we compare our results with the research by Barais et al., we found a similar occurrence of a sense of alarm (34% in our study compared to 35%) (1). The sensitivity in our study was 0.85 compared to 0.61 in France, the specificity was 0.79 compared to 0.71. The diagnostic accuracy was 0.80 CI [0.71-0.88] compared to 0.69 CI [0.64 to 0.74], a non-significant difference. Given the transculturality of gut feelings, it could be interesting to be able to repeat this study internationally with a larger sample size.
Margot Van Den Biesen, Antwerpen, 2020
- Barais M, Fossard E, Dany A, Montier T, Stolper E, Van Royen P. Accuracy of the general practitioner’s sense of alarm when confronted with dyspnoea and/or chest pain: a prospective observational study. BMJ Open. 2020 Feb;10(2):e034348.
