The ‘sense of alarm’ (‘gut feeling’) in clinical practice. A survey among European general practitioners on recognition and expression

Abstract

Objective: Most general practitioners in the Netherlands and Flanders (Belgium) are familiar with that special feeling during certain consultations: ‘There's something wrong here, though I have no specific indications yet’. This ‘sense of alarm’ alerts the doctor, activates the diagnostic process and induces him to initiate specific management to prevent serious health problems. We wanted to know whether this sense of alarm is a typical phenomenon among Dutch-speaking GPs or is also recognized by GPs elsewhere in Europe. Methods: A short questionnaire survey was held among 128 GPs in 28 countries included in the European General Practitioners Research Network (EGPRN). GPs were asked if they recognized our description of the ‘sense of alarm’ and if they used a typical phrase in their language to express this uneasy feeling. Results: We received 30 replies from GPs in 16 European countries, plus Israel and South-Africa. They all recognized our description and 25 GPs reported typical expressions in their own language. The GPs' uneasy feeling was sometimes perceived as a bodily sensation.

Conclusion: The ‘sense of alarm’ is a familiar phenomenon in general practices in Europe. We propose to use the English phrase ‘gut feelings’ in further research reports.

Key words::

• ‘Gut feelings’
• general practice
• uncertainty
• decision-making
• ‘sense of alarm’

Introduction

In some consultations, general practitioners (GPs) perceive an uneasy feeling which makes them concerned about a possible adverse outcome: ‘There's something wrong here, though I have no specific indications yet’. Something non-specific in the patient's story or presentation alerts the doctor, activates the diagnostic process and induces him or her to initiate, if possible, specific management to prevent serious health problems. Doctors in the Netherlands and Flanders (Belgium) use a typical Dutch expression for this feeling, i.e. ‘niet-pluis’, a phrase that cannot be easily translated (‘not okay’). The literature offers hardly any information about this topic. It is sometimes described as ‘a useful warning light, which suddenly lights up to announce that there is something unusual’ (1). It has also been described as ‘a wrong feeling as a way to distinguish urgent from non urgent’ and ‘a rough assessment of the situation to identify emergency problems’ (2,3). A review about diagnostic reasoning made no mention of a ‘sense of alarm’ at all (4). Our qualitative research on the description and diagnostic properties of this feeling distinguished a ‘sense of alarm’ and a ‘sense of reassurance’ (5,6). GPs (n=28) in four focus groups regarded these feelings as a compass in situations of uncertainty, and the majority of them trusted this guide.

We wanted to know whether this ‘sense of alarm’ would be recognized by other GPs in Europe, and which words they would use to refer to it. We also wanted to find a clear and recognizable English phrase for this phenomenon, to allow us to compare our research results with GPs' experiences in other European countries.

Method

In October 2005, a short questionnaire survey was sent to 128 GPs (from 28 countries) included in the European General Practitioners Research Network (EGPRN). We used the EGPRN list server ([email protected]), a discussion forum of national representatives and key persons in their country, mainly in Europe, but also in Israel and South Africa. To increase the response rate, the questionnaire was sent out again in January 2006, in personal e-mails to 28 EGPRN GPs in those European countries from which few or no responses had been received.

GPs were asked if they recognized our description of the ‘sense of alarm’ (see Table I) and if they used specific phrases in their language to express this uneasy feeling. Responses were to be given in English except for the typical phrases, and were analysed at the level of individual GPs, as we did not aim for consensus within countries.

Table I. Questionnaire.

Every Dutch-speaking GP probably knows that special sense in some consultations: ‘There's something wrong with this patient but I don't know exactly what. I have to do something for this patient because waiting longer might be bad for him or her’. It is a non-specific sense, non-analytical but important to be recognised. Something vague in the patient's story or in the presentation triggers the doctor's attention and alerts him or her. It has something to do with prognosis.

In the Netherlands and Flanders (Belgium), we use a typical expression for this sense, viz. ‘niet-pluis’. We recently started research to examine the value of this feeling, i.e. its diagnostic properties. Unfortunately, the literature offers almost nothing about this topic.

We would, therefore, like you to answer the following questions, if possible:1. Do you recognise this special sense?2. Do you have an expression or descriptive phrase for this feeling in your language? If yes, please write it down below. How would you translate this in English?

Results

We received 30 replies from GPs in 16 European countries, Israel and South Africa (see Table II). They all recognized our description, and 25 of them offered phrases or typical expressions in their own language. Ten respondents described that they perceived this uneasy feeling as a bodily sensation in the gut, the stomach or the bones or, metaphorically, as a ‘smell’.

Table II ‘Sense of alarm’ and comparable expressions in Europe.

Country	Recognition	Expression/description
Bulgaria	Yes	No specific expression.
Bulgaria	Yes	Intuition.
Croatia	Yes	Intuition, sixth sense.
Denmark	Yes	Min sjette sans sagde mig = My sixth sense tells me something is wrong.Noget i min mave fortalte mig = something in my stomach told me or my gut feeling told me.Et eller andet sagde mig at noget er galt = something tells me something is wrong.
France	Yes	Sentiment d'ėtrangetė = a sense of something strange.
France	Yes	Peut-être intuition ou intime conviction = one's innermost conviction.
France	Yes	Mauvais presentiment ou mauvaise premonition = ominous feeling or a bad premonition.
Germany	Yes	Alarmgefűhl = sense of alarm.
Germany	Yes	Hier stimmt was nicht = there's something wrong here.
Germany	Yes	Ahnung. Gefűhl = suspicion, feeling.
Greece	Yes	K = there is something I don't like.K = something ‘smells’ here.K = there is something that does not ‘stick’ here.
Greece	Yes	K = something will come to me or happen to me or something is coming.
Hungary	Yes	Megmagyarazkatatlan allapotromlas = unexplained detoriation. Valami nem tetstik = something dislike.
Israel	Yes	Gut feeling, abdominal sensations.
Israel	Yes	No expression in Hebrew; sixth sense.
Italy	Yes	No.
Italy	Yes	Brutto presentimento = an uneasy premonition.
Italy	Yes	No specific expression.
Malta	Yes	Ixxomm xi haga = something ‘smells’.
Norway	Yes	Magefølelse = feeling in my stomach.Noe som ikke stemmer = something that doesn't fit in.Pasienten virker syk = patient seems ill.
Norway	Yes	Dårlig magefǿlelse = bad feeling in the stomach.
Portugal	Yes	sexto sentido = sixth sense.
Romania	Yes	No specific expression.
South Africa	Yes	Gut feel. Instinct.
Serbia/Montenegro	Yes	Neobjasnjivo zdravstveno stanje = unexplained health condition.Svestan opasnosti = alert to danger.Potencijalno opasno zdravstveno stanje = potential dangerous health condition.
Switzerland	Yes	Mon petit doigt me dit, intuition = my little finger says.
Turkey	Yes	Koku var = this has a smell, this case ‘smells’.
UK	Yes	Gut feeling.Uncertain feeling but needing to do something.
UK	Yes	I have a feeling in my bones.
UK	Yes	Clinical hunch or sixth sense that something serious is going on or clinical intuition.

Seven of the respondents added comments. A Danish GP reported about the necessity of teaching young doctors to trust this ‘fingertip’ feeling or the ‘sense in your nose’. Norwegian GPs described it as a kind of intuition, based on expertise, pattern recognition, bodily empathy or tacit knowledge. These so-called ‘gut feelings’ are not mystical, despite the fact that GPs are not fully aware of all information they absorb and process in a clinical situation. The ‘sense of alarm’ has something to do with coping with uncertainty, as one GP from the UK wrote.

Discussion

Although the response rate (24%) was rather low, it seems justified to conclude that the ‘sense of alarm’ is a familiar phenomenon in general practice all over Europe. The non-response from some European countries, such as Austria, Estonia, Finland, Slovenia, Spain and Sweden, does not invalidate our conclusions, since we received positive answers from 16 of the 28 countries and we already knew that the ‘sense of alarm’ is well-known in the Netherlands and Belgium.

Since the results of our survey show a frequent link to bodily sensations, we propose to use the English phrase ‘gut feelings’ in further research reports to represent the twin concepts of ‘sense of alarm’ and ‘sense of reassurance’. It seems worthwhile to establish a European research agenda to validate the concept and to study its value for daily practice routine and education.

Funding

There was no funding.

Ethical permission

Since no patients were involved and GPs were only asked about their opinions and perceptions, this research did not fall under the Dutch Medical Research Involving Human Subjects Act (WMO) or the Embryos Act, so that no ethical permission was required.

Acknowledgement

The authors thank the EGPRN for the use of their e-mail list server.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.