EBM and gut feelings

Dear Sir

We have, appreciatively, read the article “Factors influencing the EBM behaviour of GP trainers” (te Pas et al. 2013). Evidence-based Medicine (EBM) stands for integrating individual clinical expertise with the best clinical evidence and the patient's condition and preferences. The authors conclude from their study that general practitioner (GP) trainers associate EBM with clinical evidence and do not consider clinical experience as part of the definition. In our view, the authors strengthen this interpretation by the questionnaires used in their study. These questionnaires focus on the search and use of evidence regarding clinical questions and not on the integration of the evidence with clinical expertise and patient's wishes. We think that knowledge and understanding of the EBM definition alone do not help to promote evidence-based practice, as long as we do not have more insight in how the different elements of the definition must be integrated. The focus group study contributes to this by reporting barriers to the use of EBM in general practice.

The authors report in their discussion that GP trainers taught their trainees “something else” than EBM. They state that this “something else” could be referred to as “gut feeling” and call it the “GP feeling” in their conclusion. We think the GP trainers referred to their clinical expertise in general as well as to their knowledge about patients and not only to the very specific concept of gut feeling. In our definition, a GP's gut feeling refers to a feeling of reassurance or alarm that automatically arises based on the interaction of the patient's information and the physician's knowledge and experience (Stolper et al. 2011). A gut feeling may stimulate a GP to formulate and weigh up working hypotheses involving a serious outcome. In the diagnostic process, analytical and non-analytical cognitive processes continuously interact. The affective component of gut feelings complements automatic reasoning based on experiential knowledge, and deliberate reasoning including the use of clinical evidence in medical decision making.