Establishing a European research agenda on ‘gut feelings’ in general practice. A qualitative study using the nominal group technique

Figures & data

Table I. Consensus on ‘gut feelings’: ‘alarm’ and ‘reassurance’ (4).

A ‘sense of alarm’

• A ‘sense of alarm’ means that a GP perceives an uneasy feeling as he/she is concerned about a possible adverse outcome.

• A ‘sense of alarm’ implies that a GP worries about a patient's health status, even though he/she has found no specific indications yet; it is a sense of ‘there's something wrong here’.

• A ‘sense of alarm’ activates the diagnostic process by stimulating a GP to formulate and weigh up working hypotheses that might involve a serious outcome.

• A ‘sense of alarm’ means that, if possible, the GP needs to initiate specific management to prevent serious health problems

• A ‘sense of alarm’ will decrease as the diagnosis and the right management become clearer.

A ‘sense of reassurance’

• A ‘sense of reassurance’ means that a GP feels secure about the further management and course of a patient's problem, even though he/she may not be certain about the diagnosis: everything fits in.

• The ‘sense of reassurance’ and the ‘sense of alarm’ constitute a dynamic element in a GP's diagnostic process.

Table II. Rating of all research questions on ‘gut feelings’ and appropriate study designs by three groups of experts.

	Ratings of group A		Ratings of group B		Ratings of group C
Rating	Aim	Design	Aim	Design	Aim	Design
1	Validation of determinants and cues Experience, context	Recording; (A) Intervention (F)	Diagnostic value Prevalence, relevance, test properties.	Recording, follow-up (A),	Diagnostic value Prevalence, relevance, test properties.	Recording, follow-up (A)
2	Diagnostic value Prevalence, relevance, test properties	Recording, follow-up; (A) Reflection after consultation (B)	Validation of determinants and cues Inter-doctor variation	(–)	Validation of determinants and cues Experience, context	Video recording; (C) Video stimulated recall (C)
3	Other Finding cut-off points	Manipulation in vignette studies (D)	Other Biological variables	Measuring heart rate and skin resistance (I)	Setting as a determinant	Recording, surgery versus out-of-office; Acute versus chronic (A)
4	Validation of determinants and cues Experience	Analysis of cases after consultation (C)	Validation of determinants and cues Setting as a determinant	Recording, surgery versus out-of-office; Acute versus chronic (A)	Other determinants	Case vignettes study (D)
5	Other Inter-doctor variation	Stimulated recall after observing video tapes (C)	Other Non-verbal elements	(–)	Other Doctor–patient differences	(–)
6			Validation of determinants and cues Expertise	Comparing experts and trainees; (E) Video observation (C)	Influence on guideline compliance	(–)
7			Other Semantic differences in interpretation	Linguistic analyses (H)	Validation of determinants and cues	Conversation analysis (H)
8		Medical education		Trainees telling their stories. Studying videos (G)

Legend: for (A)-(I) see Table IV.

Table III. Results: research questions on ‘gut feelings’.

Diagnostic value (outcome)

• What is the prevalence of the ‘sense of alarm’ and the ‘sense of reassurance’?

• What are the diagnostic relevance and benefits of ‘gut feelings’? Is it possible to calculate their test properties? Are there differences in the prevalence of ‘gut feelings’ and the outcome between normal surgery hour services and services during out-of-office hours? Are there differences between GPs?

Validation of determinants and cues (process)

• What do specific professional-related determinants such as work-experience contribute to ‘gut feelings’? Are there differences between GPs? What is the significance of the contextual information? Which cues can be found by studying determinants?

Medical education (teaching)

• Can the concept of ‘gut feelings’ be used in medical education? Can ‘gut feelings’ be taught to young doctors?

Rest group: other research questions

• Are there measurable biological parameters of ‘gut feelings’ that would allow researchers to find more evidence?

• What minimum level of a priori disease probability is needed to experience a ‘sense of alarm’?

• What are the semantic differences and agreements between GPs in the interpretation of terms about ‘gut feelings’?

• Are there differences in the prevalence of gut feelings between GPs and their patients? Do patients' ‘gut feelings’ influence the diagnostic reasoning of GPs?

• Can ‘gut feelings’ explain the sometimes low compliance of GPs with guidelines?

• Which non-verbal elements related to ‘gut feelings’ do GPs observe?

Table IV. Results: Study designs for research on ‘gut feelings’.

A. Recording ‘gut feelings’, determinants, expected outcome (ICPC), in surgery and out of office hours. Follow-up after three months. Problem: which reference standard?

B. Stimulated recall after surgery: selection of patients on the basis of a strong sense of alarm; reflection on determinants afterwards.

C. Stimulated recall by experienced GPs and trainees after encounters with simulation patients. Same design but after observing video tapes with real patients.

D. Studies based on vignettes.

E. Experimental study with an intervention in the form of a short course to make participants aware of gut feelings and their significance involving students, inexperienced GPs and experienced GPs.

F. Experimental study with an intervention in the form of reflection after each consultation; recording ‘gut feelings’ and determinants.

G. Giving trainees an opportunity to tell their consultation stories and analyse the role of ‘gut feelings’. Studying videotapes with real patients.

H. Conversation analysis or linguistic analysis of transcripts of consultations.

I. Measuring heart rate and skin resistance during office hours with simulation patients or during observations of video-taped consultations.

Stolper CF, Van Royen P, Van Bokhoven MA, Houben PHH, Van de Wiel M, Van der Weijden T, . Consensus on gut feelings in general practice. BMC Fam Pract. 2009;10:66.

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