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From the trainer

From the trainer InnovAiT, InnovAiT, 11(6), 11(6), 321 321 From From the the trainer trainer Trust Trust your your instincts instincts Dr Dr Lizzie Lizzie Heptinstall Heptinstall ST3 ST3 Hackney Hackney GPVTS. GPVTS. Email: Email: elizabeth.h@hotmail.co.uk elizabeth.h@hotmail.co.uk Dr Dr Dominic Dominic Roberts Roberts Program Program Director, Director, Hackney Hackney GPVTS GPVTS Medicine Medicine is is complex; complex; the the challenge challenge of of data data gathering gathering then then formulating formulating the the absence absence of of aa gut gut instinct instinct of of something something being being wrong wrong with with the the an an action action plan plan and and diagnosis diagnosis is is not not always always easy, easy, and and it it is is not not too too patient patient decreased decreased the the probability probability of of serious serious infection infection from from 0.2% 0.2% to to uncommon uncommon for for doctors doctors to to get get caught caught out out with with aa rare rare or or atypical atypical pres- pres- 0.1%. 0.1%. entation. entation. II often often think think that that GPs GPs are are statisticians, statisticians, be-it be-it subconsciously subconsciously or or It It seems seems that that aa majority majority of of us us rely rely on on our our instincts instincts when when presented presented consciously, consciously, in in that that we we pick pick out out the the patient patient that that doesn’t doesn’t fit fit into into the the with with aa quandary. quandary. A A focus focus group group in in the the Netherlands Netherlands found found that that aa major- major- numerous numerous presentations presentations and and act act appropriately. appropriately. ity ity of of (a (a sample sample of of 28) 28) GPs GPs felt felt that that gut gut instinct instinct helped helped their their daily daily Within Within the the field field of of medicine, medicine, we we are are aware aware that that our our work work is is far far practice practice remain remain safe safe when when the the evidence evidence was was not not able able to to back back up up from from pure pure science; science; experience experience is is assimilated assimilated with with knowledge knowledge in in order order their their suspicions suspicions of of serious serious illness. illness. However, However, in in Van Van den den Bruel’s Bruel’s to to expertly expertly manage manage those those with with the the common common and and the the obscure obscure with with paper, paper, six six of of the the 527 527 cases cases of of serious serious illness illness were were missed, missed, of of which which equal equal competence, competence, albeit albeit perhaps perhaps not not the the same same diagnostic diagnostic timeframe. timeframe. two two might might have have been been picked picked up up had had the the doctors doctors listened listened to to their their gut gut However, However, medicine medicine has has long long been been known known as as an an art art form, form, something something instinct; instinct; she she notes notes that that this this would would be be at at the the cost cost of of 44 44 false false alarms; alarms; more more nebulous nebulous than than the the acquisition acquisition of of facts facts and and numbers numbers into into algo- algo- clearly clearly even even instinct instinct cannot cannot always always get get it it right. right. rithmic rithmic conclusions. conclusions. So, So, on on what what can can we we rely rely when when the the algorithms algorithms and and When When our our instincts instincts lead lead to to no no clinical clinical diagnosis diagnosis and and the the patient patient blood blood tests tests fall fall aa little little flat? flat? Some Some describe describe aa ‘gut ‘gut feeling’ feeling’ has has protected protected resolves resolves to to recover recover or or remain remain well, well, this this can can shake shake our our confidence confidence and and them them when when the the evidence evidence simply simply won’t won’t stack stack in in their their favour. favour. belief belief in in the the value value of of trusting trusting our our instincts, instincts, yet yet it it seems seems to to be be something something Many Many aa medic medic has has aa dinner dinner anecdote anecdote of of the the patient patient who who just just did did not not we we should should recognise recognise value value from from early early in in our our careers, careers, when when experience experience seem seem right, right, despite despite normal normal observations observations or or recent recent reassuring reassuring blood blood and and knowledge knowledge are are yet yet to to be be cemented cemented into into clinical clinical practice. practice. tests. tests. When When we we pick pick up up on on aa patient’s patient’s illness illness despite despite the the hard hard data data Interestingly, Interestingly, in in Van Van den den Bruel’s Bruel’s observational observational study, study, she she notes notes that that reassuring reassuring us us otherwise, otherwise, are are we we engaging engaging in in more more subtle subtle experience- experience- the the diagnostic diagnostic value value of of the the gut gut instinct instinct is is no no better better in in more more or or less less based based pattern pattern recognition? recognition? Could Could it it be be the the vestigial vestigial fight fight or or flight flight experienced experienced clinicians, clinicians, suggesting suggesting that that it it stems stems from from something something more more response response letting letting us us know know that that something something is is not not right; right; is is our our ancient ancient inherent inherent in in our our ability ability to to assess assess and and relate relate to to other other people, people, perhaps perhaps midbrain midbrain protecting protecting our our modern modern patients? patients? When When we we consider consider instincts, instincts, emotional emotional intelligence. intelligence. we we think think of of impulse-related impulse-related decisions decisions that that have have an an innate innate sense sense of of It It seems seems that that instinct, instinct, in in its its intangible intangible state state provides provides less less experi- experi- ‘safety ‘safety first’; first’; caution caution when when walking walking somewhere somewhere alone alone or or aa sense sense that that enced enced clinicians clinicians with with aa warning warning system system when when we we have have yet yet to to accrue accrue someone someone is is lying. lying. II wonder wonder if if this this sort sort of of instinct instinct plays plays aa bigger bigger role role in in the the experience experience to to assuage assuage our our own own self-imposed self-imposed clinical clinical doubt. doubt. If If general general practice practice than than we we realise. realise. Indeed, Indeed, Ann Ann Van Van den den Bruel Bruel wrote wrote in in listened listened to, to, it it also also allows allows more more experienced experienced clinicians clinicians aa second second the the BMJ BMJ in in 2012 2012 that that in in the the absence absence of of objective objective clinical clinical data, data, aa gut gut glance glance at at the the ordinary ordinary patient patient with with something something not not quite quite right; right; the the instinct instinct of of something something being being wrong wrong significantly significantly increased increased the the likeli- likeli- luxury luxury of of aa subconscious subconscious nudge nudge to to take take note note despite despite well-learnt well-learnt clin- clin- hood hood of of aa correct correct diagnosis diagnosis of of serious serious infection. infection. She She also also notes notes that that ical ical rote rote actions. actions. In In essence, essence, trust trust your your instincts! instincts! References References and and further further information information Van Van den den Bruel, Bruel, A A., ., Thompson, Thompson, M., M., Buntinx, Buntinx, F., F., & & serious serious infections infections in in children: children: observational observational Stolper, Stolper, E., E., van van Bokhoven, Bokhoven, M., M., Houben, Houben, P., P., Van Van feelings feelings in in general general practice practice – – A A ffocus ocus group group study study Mant, Mant, D D.. (2012). (2012). Clinicians’ Clinicians’ gut gut feeling feeling about about study. study. BMJ BMJ,, 345 345,, e6144. e6144. doi: doi: 10/1136/bmj.e6144 10/1136/bmj.e6144 Royen, Royen, P., P., van van de de Wiel, Wiel, M M., ., van van der der Weijden, Weijden, T., T., of of the the concept concept and and its its determinants. determinants. BMC BMC Family Family & & Jan Jan Dinant, Dinant, G G.. (2009). (2009). The The diagnostic diagnostic role role o off gut gut Practice Practice,, 18 18,, 17. 17. doi: doi: 10.1186/1471-2296-10-17 10.1186/1471-2296-10-17 InnovAiT, 2018, Vol. 11(6), 321, ! The Author(s) 2018. DOI: 10.1177/1755738018762526 321 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav journals.sagepub.com/home/ino http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png InnovAiT: Education and inspiration for general practice SAGE

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Abstract

InnovAiT, InnovAiT, 11(6), 11(6), 321 321 From From the the trainer trainer Trust Trust your your instincts instincts Dr Dr Lizzie Lizzie Heptinstall Heptinstall ST3 ST3 Hackney Hackney GPVTS. GPVTS. Email: Email: elizabeth.h@hotmail.co.uk elizabeth.h@hotmail.co.uk Dr Dr Dominic Dominic Roberts Roberts Program Program Director, Director, Hackney Hackney GPVTS GPVTS Medicine Medicine is is complex; complex; the the challenge challenge of of data data gathering gathering then then formulating formulating the the absence absence of of aa gut gut instinct instinct of of something something being being wrong wrong with with the the an an action action plan plan and and diagnosis diagnosis is is not not always always easy, easy, and and it it is is not not too too patient patient decreased decreased the the probability probability of of serious serious infection infection from from 0.2% 0.2% to to uncommon uncommon for for doctors doctors to to get get caught caught out out with with aa rare rare or or atypical atypical pres- pres- 0.1%. 0.1%. entation. entation. II often often think think that that GPs GPs are are statisticians, statisticians, be-it be-it subconsciously subconsciously or or It It seems seems that that aa majority majority of of us us rely rely on on our our instincts instincts when when presented presented consciously, consciously, in in that that we we pick pick out out the the patient patient that that doesn’t doesn’t fit fit into into the the with with aa quandary. quandary. A A focus focus group group in in the the Netherlands Netherlands found found that that aa major- major- numerous numerous presentations presentations and and act act appropriately. appropriately. ity ity of of (a (a sample sample of of 28) 28) GPs GPs felt felt that that gut gut instinct instinct helped helped their their daily daily Within Within the the field field of of medicine, medicine, we we are are aware aware that that our our work work is is far far practice practice remain remain safe safe when when the the evidence evidence was was not not able able to to back back up up from from pure pure science; science; experience experience is is assimilated assimilated with with knowledge knowledge in in order order their their suspicions suspicions of of serious serious illness. illness. However, However, in in Van Van den den Bruel’s Bruel’s to to expertly expertly manage manage those those with with the the common common and and the the obscure obscure with with paper, paper, six six of of the the 527 527 cases cases of of serious serious illness illness were were missed, missed, of of which which equal equal competence, competence, albeit albeit perhaps perhaps not not the the same same diagnostic diagnostic timeframe. timeframe. two two might might have have been been picked picked up up had had the the doctors doctors listened listened to to their their gut gut However, However, medicine medicine has has long long been been known known as as an an art art form, form, something something instinct; instinct; she she notes notes that that this this would would be be at at the the cost cost of of 44 44 false false alarms; alarms; more more nebulous nebulous than than the the acquisition acquisition of of facts facts and and numbers numbers into into algo- algo- clearly clearly even even instinct instinct cannot cannot always always get get it it right. right. rithmic rithmic conclusions. conclusions. So, So, on on what what can can we we rely rely when when the the algorithms algorithms and and When When our our instincts instincts lead lead to to no no clinical clinical diagnosis diagnosis and and the the patient patient blood blood tests tests fall fall aa little little flat? flat? Some Some describe describe aa ‘gut ‘gut feeling’ feeling’ has has protected protected resolves resolves to to recover recover or or remain remain well, well, this this can can shake shake our our confidence confidence and and them them when when the the evidence evidence simply simply won’t won’t stack stack in in their their favour. favour. belief belief in in the the value value of of trusting trusting our our instincts, instincts, yet yet it it seems seems to to be be something something Many Many aa medic medic has has aa dinner dinner anecdote anecdote of of the the patient patient who who just just did did not not we we should should recognise recognise value value from from early early in in our our careers, careers, when when experience experience seem seem right, right, despite despite normal normal observations observations or or recent recent reassuring reassuring blood blood and and knowledge knowledge are are yet yet to to be be cemented cemented into into clinical clinical practice. practice. tests. tests. When When we we pick pick up up on on aa patient’s patient’s illness illness despite despite the the hard hard data data Interestingly, Interestingly, in in Van Van den den Bruel’s Bruel’s observational observational study, study, she she notes notes that that reassuring reassuring us us otherwise, otherwise, are are we we engaging engaging in in more more subtle subtle experience- experience- the the diagnostic diagnostic value value of of the the gut gut instinct instinct is is no no better better in in more more or or less less based based pattern pattern recognition? recognition? Could Could it it be be the the vestigial vestigial fight fight or or flight flight experienced experienced clinicians, clinicians, suggesting suggesting that that it it stems stems from from something something more more response response letting letting us us know know that that something something is is not not right; right; is is our our ancient ancient inherent inherent in in our our ability ability to to assess assess and and relate relate to to other other people, people, perhaps perhaps midbrain midbrain protecting protecting our our modern modern patients? patients? When When we we consider consider instincts, instincts, emotional emotional intelligence. intelligence. we we think think of of impulse-related impulse-related decisions decisions that that have have an an innate innate sense sense of of It It seems seems that that instinct, instinct, in in its its intangible intangible state state provides provides less less experi- experi- ‘safety ‘safety first’; first’; caution caution when when walking walking somewhere somewhere alone alone or or aa sense sense that that enced enced clinicians clinicians with with aa warning warning system system when when we we have have yet yet to to accrue accrue someone someone is is lying. lying. II wonder wonder if if this this sort sort of of instinct instinct plays plays aa bigger bigger role role in in the the experience experience to to assuage assuage our our own own self-imposed self-imposed clinical clinical doubt. doubt. If If general general practice practice than than we we realise. realise. Indeed, Indeed, Ann Ann Van Van den den Bruel Bruel wrote wrote in in listened listened to, to, it it also also allows allows more more experienced experienced clinicians clinicians aa second second the the BMJ BMJ in in 2012 2012 that that in in the the absence absence of of objective objective clinical clinical data, data, aa gut gut glance glance at at the the ordinary ordinary patient patient with with something something not not quite quite right; right; the the instinct instinct of of something something being being wrong wrong significantly significantly increased increased the the likeli- likeli- luxury luxury of of aa subconscious subconscious nudge nudge to to take take note note despite despite well-learnt well-learnt clin- clin- hood hood of of aa correct correct diagnosis diagnosis of of serious serious infection. infection. She She also also notes notes that that ical ical rote rote actions. actions. In In essence, essence, trust trust your your instincts! instincts! References References and and further further information information Van Van den den Bruel, Bruel, A A., ., Thompson, Thompson, M., M., Buntinx, Buntinx, F., F., & & serious serious infections infections in in children: children: observational observational Stolper, Stolper, E., E., van van Bokhoven, Bokhoven, M., M., Houben, Houben, P., P., Van Van feelings feelings in in general general practice practice – – A A ffocus ocus group group study study Mant, Mant, D D.. (2012). (2012). Clinicians’ Clinicians’ gut gut feeling feeling about about study. study. BMJ BMJ,, 345 345,, e6144. e6144. doi: doi: 10/1136/bmj.e6144 10/1136/bmj.e6144 Royen, Royen, P., P., van van de de Wiel, Wiel, M M., ., van van der der Weijden, Weijden, T., T., of of the the concept concept and and its its determinants. determinants. BMC BMC Family Family & & Jan Jan Dinant, Dinant, G G.. (2009). (2009). The The diagnostic diagnostic role role o off gut gut Practice Practice,, 18 18,, 17. 17. doi: doi: 10.1186/1471-2296-10-17 10.1186/1471-2296-10-17 InnovAiT, 2018, Vol. 11(6), 321, ! The Author(s) 2018. DOI: 10.1177/1755738018762526 321 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav journals.sagepub.com/home/ino

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InnovAiT: Education and inspiration for general practice – SAGE

Published: Jun 1, 2018

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