Thirteenth tip for teaching expertise in clinical reasoning

Dear Sir

We have, appreciatively, read Joseph Rencic's ‘Twelve tips for teaching expertise in clinical reasoning’ (Rencic 2011). We would like, however, to complete this survey with a thirteenth tip: ‘take your gut feelings seriously’. Gut feelings are based on the interaction between patient information and a physician's knowledge and experience. (Stolper et al. 2011)

Most physicians will recognize that feeling of sudden heightened awareness or alarm, which sometimes emerges during consultation. That sense of alarm is an uneasy feeling, a sense of ‘there's something wrong here’ which activates the diagnostic process by stimulating a physician to formulate provisional hypotheses with potentially serious outcomes and to weigh them against each other. On the other hand, a sense of reassurance means that a physician may feel confident about the management plan and/or about the outcome, even though he/she is not certain about the diagnosis: ‘it all adds up’. These gut feelings act as a compass, a kind of skilled intuition (Kahneman & Klein 2009), steering physicians through busy office hours and making complex situations manageable. Most GPs trust this compass. Dual-process theories contrast analytical reasoning like the use of Bayes theorem and decision trees, and non-analytical reasoning like pattern recognition and gut feelings as two continually interacting modes of knowing and thinking (Stolper et al. 2011). Gut feelings may alert physicians to slow down switching to analytical reasoning. Cognitive neuroscience research provides support for the view that emotions are a vital component of the decision making process, helping us to thread our ways through the huge amount of information and knowledge. As Rencic already wrote: a combined non-analytical and analytical approach to clinical reasoning improves diagnostic accuracy.

Increased awareness of gut feelings, feedback, reflection and specific experience may help students to learn when to trust gut feelings and when to slow down.

C.F. Stolper, M.W.J. van de Wiel, M.A. van Bokhoven, T. van der Weijden, G.J. Dinant, CAPHRI School for Public Health and Primary Care, Maastricht University, P.O. Box 616 6200 MD, Maastricht, The Netherlands. E-mail: [email protected]

P. Van Royen, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium