by Sophie Turnbull
PhD Student
Centre for Academic Primary Care
Clinician intuition and gut feelings are often talked about in health care but are largely mysterious. Clinicians describe just knowing that there was something wrong with a patient but not exactly how they came to that conclusion.
In a recent study we aimed to unpick how clinicians form their gut feelings, how they use them to influence treatment decisions, and whether their gut feeling was good at predicting whether a child with infectious cough would get sicker in the 30 days after seeing them.
Using gut feeling to predict outcome in children with infectious cough
Infectious cough in children is the most common problem managed by health services internationally. Although the majority of children get better on their own, a small proportion end up hospital with a serious illness. Clinicians do not always find it easy to establish a diagnosis or to feel confident whether the child’s illness will get better or worse. This can lead them to prescribing antibiotics just in case they might get ill, which is contributing to antibiotic resistance. In cases where the clinician feels uncertain about the diagnosis or whether the child will get better, clinician gut feelings are believed to influence the decisions the clinician makes on how to manage the child’s illness.
TARGET was a large study of over 8,300 children that aimed to get a better understanding of what happens to children with infectious cough in the 30 days after they see a clinician at a GP practice. The primary aim of the study was to develop a prediction rule that could identify which children would be hospitalised in the next 30 days, designed to help clinicians improve their use of antibiotics. As part of this study, information was collected about whether a clinician had a gut feeling something was wrong with the child and what treatment decisions the clinician made (prescribed antibiotics or referred to hospital) when they saw them at the GP practice. Information was then collected about whether the child’s condition had worsened such that they had to return to see the clinician or be admitted to hospital.
From this, we conducted a secondary analysis, the main aims of which were to understand:
1) what clinician and child characteristics were associated with a clinician reporting that they had a gut feeling something was wrong
2) whether clinician gut feeling influenced how they decided to treat the child
3) whether the clinician having a gut feeling something was wrong was a good predictor of whether the child’s illness would get worse.
We found that clinicians who had been trained for longer were more likely to report that they had a gut feeling something was wrong. They were also more likely to have a gut feeling if the child had symptoms and signs that suggested they were more unwell. The clinician having a gut feeling meant it was much more likely they would prescribe antibiotics and refer the child for hospitalisation. However, we found that clinician gut feeling was not a good predictor of the child’s illness getting worse: that is, either resulting in a return to the GP or being admitted to hospital.
This suggests that although clinicians are using their gut feeling to help them decide how to treat the patients, it may not be the best indicator of how sick the child is (in a separate analysis we identified seven characteristics that best predicted hospitalisation).
Links with a learning perspective of intuition
These findings are supported by the learning perspective of intuition, which suggests that intuition is the result of the clinician unconsciously using knowledge of patterns of signs and symptoms that they have developed through their years of experience. These patterns may be influenced by previous experiences of negative outcomes, such as not treating a child in the past who went on to be very ill or possibly died.
As demonstrated by our findings, being more experienced does not necessarily mean gut feelings are more accurate. The validity of the gut feeling as a guide to decision-making relies not only on the quantity (years of experience), but also the quality of the feedback on what happens next. If there is good feedback during the learning process, this results in good or accurate gut feeling and decision-making. But, poor or absent feedback results in poor intuition.
Over-valuing gut feeling in the absence of objective information
Given the high levels of uncertainty reported by clinicians looking after this group of patients, it is not surprising they wish to use all the tools at their disposal, including their gut feeling. However, our results suggest some clinicians may over-value gut feeling in their clinical decision making in children with infectious cough and that they are using gut feeling as an unconscious marker of other important symptoms and signs.
Gut feeling may have value in the absence of known, objectively assessed markers of risk. However, attending to objective assessment of these risks is preferable when this information is available.
Paper: ‘What gives rise to clinician gut feeling, its influence on management decisions and its prognostic value for children with RTI in primary care: a prospective cohort study’. S. Turnbull, Patricia J. Lucas, Niamh M. Redmond, Hannah Christensen, Hannah Thornton, Christie Cabral, Peter S. Blair, Brendan C. Delaney, Matthew Thompson, Paul Little, Tim J. Peters, and Alastair D. Hay. BMC Family Practice. 2018. Feb 5.
PhD funded by the NIHR School for Primary Care Research.
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Related posts:
Why are so many children given antibiotics for a cough? by Dr Christie Cabral
Safety-netting advice: my experience as an Academic Foundation Programme doctor by Dr Peter Edwards