The complex power of the gut

Expert clinical practice is increasingly identified as being inclusive of more than merely conscious ways of knowing and behaving. We define ‘conscious’ here as ‘thought or deliberation with conscious attention directed at the problem’ (3). ‘Attention’ is referred to as ‘the selective processing of one aspect while ignoring other irrelevant aspects’ (3). Experience leads practitioners to use an embodied reality of unconscious thoughts (4). These are personal, contextual and ‘in-the-moment’ thoughts, or in other words ‘gut feelings’ (1,2,5,6). General practitioners (GPs) base their snap judgement of for instance the presence of depression mainly on unconscious clinical thoughts (7). Such pattern recognition is reflexive, not reflective. We do it, yet usually cannot explain to others how we do it (8). Snap judgements and rapid cognition take place behind a locked door (9).

Most GPs somehow recognize or allow such special yet vague diagnostic feelings during certain consultations. This ‘sense of alarm’ alerts, activates the diagnostic process and induces specific management steps to prevent serious health problems. When asked, the GP is not able to tell what happens. The reverse, a sense of reassurance, is also recognizable. It slows down the diagnostic process and induces a wait-and-see policy. A GP may even perceive such diagnostic ‘feelings’ as bodily sensations. These floating irrational feelings have been the subject of a number of laudable first studies into this complicated domain (1,2,5,6).

Stolper et al. (1,2), the authors of these studies, have studied the unconscious decision-making, but they call it ‘gut feelings’. It is remarkable that they refrain from using a definition like the one above (attention defines conscious/unconscious). They aim to coin a new phrase for a phenomenon that has been studied in other disciplines than general practice for a long time, and may better be described as unconscious. Their concept does not build on existing theoretical concepts developed in other disciplines: gut-feelings may not be unique to general practice. As a general rule, we should always consider the possibility that practice is ahead of (general practice) research, and we agree with the general idea of Stolper et al., that diagnostic gut feelings in general practice may be uncharted territory. However, recent cognitive psychology research shows that, although Stolper et al., consider their gut feelings to be a new and particular theme for general practice research, a wealth of valuable knowledge and evidence about the locked door of immediate unconscious pattern recognition is already available (10). Stolper et al., seem to be unaware of this research (1,2).

Goals are the tools with which people engage in volitional behaviour such as learning. While goal pursuit was traditionally assumed to be strongly related to consciousness, recent research strongly suggests this is not the case (9). Indeed, goal pursuit often proceeds entirely unconsciously. One interesting hypothesis is that active learning, propagated in problem based curricula, may be more effective because it stimulates early goal development (11).

An important characteristic of conscious thought is that is considered rule-based and very precise, but has a limited capacity. Unconscious thought can conform to rules in that it detects recurring patterns but is less precise. During unconscious thought, large amounts of information can be integrated into an evaluative summary judgment (10). Dijksterhuis et al., formulated and tested the deliberation-without-attention hypothesis, which means that unconscious thought leads to better choices than conscious thought under complex circumstances (2). Conscious thought may be better for simple decisions.

The question remains where ‘gut feelings’ bring us and where the proposed research agenda can lead us. The ‘sense of alarm’ may be a familiar phenomenon in general practices in Europe, as one of the papers finds, but the questions remain how and why it should be studied, and how it can best be applied. Gladwell gives the example of a female musician who was rejected for several auditions until she had the opportunity to play behind a screen, when her skills were instantly recognized and she was appointed (8). The quality of unconscious decision making may be a function of clinical exposure or experience, and may be used to underpin how experience breeds better doctors (12). The question is how one can train the unconscious.

There is also a communication side to studying the role of unconscious thought in medical decision- making: a good doctor knows the patient, and general practice patients generally know their doctor well. Although most GPs are literate and competent in technological skills and biomedical diagnosis, they place value on connection, in the context of a holistic model of health care. This may lead them to listen to and follow their ‘inner voice,’ rather than operating only according to protocols and standard parameters. To call attention to GPs’ utilization of and reliance on unconscious thoughts or intuition as a guide to action and decision-making is, therefore, a worthwhile undertaking. A meeting with a doctor, especially in primary care, is a meeting between at least three realities: one's subjective reality as a patient, the subjective personal reality of the doctor, and the objective ‘impersonal’ reality of medicine. If a patient wants to find common ground in a good dialogue, all realities are probably at least as important. Interaction is the best possible outcome of a medical meeting (13).

Conclusion

To help GPs making complex decisions, unconscious thoughts or gut feelings deserve to be studied. Although perhaps frightening, we probably are wise to delegate some decisions about complex matters to the unconscious, in the blink of the first two seconds when a patient enters the surgery. We should heed prejudice, however.

Declaration of interest: The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.