Role of intuitive knowledge in the diagnostic reasoning of hospital specialists: a focus group study

The AI Future of Emergency Medicine

In the coming years, artificial intelligence (AI) and machine learning will likely give rise to profound changes in the field of emergency medicine, and medicine more broadly. This article discusses these anticipated changes in terms of 3 overlapping yet distinct stages of AI development. It reviews some fundamental concepts in AI and explores their relation to clinical practice, with a focus on emergency medicine. In addition, it describes some of the applications of AI in disease diagnosis, prognosis, and treatment, as well as some of the practical issues that they raise, the barriers to their implementation, and some of the legal and regulatory challenges they create.

Acute internal medicine physicians' clinical intuition based on acute care telephone referral: A prospective study

INTRODUCTION

In the Netherlands, most emergency department (ED) patients are referred by a general practitioner (GP) or a hospital specialist. Early risk stratification during telephone referral could allow the physician to assess the severity of the patients' illness in the prehospital setting. We aim to assess the discriminatory value of the acute internal medicine (AIM) physicians' clinical intuition based on telephone referral of ED patients to predict short-term adverse outcomes, and to investigate on which information their predictions are based.

METHODS

In this prospective study, we included adult ED patients who were referred for internal medicine by a GP or a hospital specialist. Primary outcomes were hospital admission and triage category according to the Manchester Triage System (MTS). Secondary outcome was 31-day mortality. The discriminatory performance of the clinical intuition was assessed using an area under the receiver operating characteristics curve (AUC). To identify which information is important to predict adverse outcomes, we performed univariate regression analysis. Agreement between predicted and observed MTS triage category was assessed using intraclass and Spearman's correlation.

RESULTS

We included 333 patients, of whom 172 (51.7%) were referred by a GP, 146 (43.8%) by a hospital specialist, and 12 (3.6%) by another health professional. The AIM physician's clinical intuition showed good discriminatory performance regarding hospital admission (AUC 0.72, 95% CI: 0.66-0.78) and 31-day mortality (AUC 0.73, 95% CI: 0.64-0.81). Univariate regression analysis showed that age ≥65 years and a sense of alarm were significant predictors. The predicted and observed triage category were similar in 45.2%, but in 92.5% the prediction did not deviate by more than one category. Intraclass and Spearman's correlation showed fair agreement between predicted and observed triage category (ICC 0.48, Spearman's 0.29).

CONCLUSION

Clinical intuition based on relevant information during a telephone referral can be used to accurately predict short-term outcomes, allowing for early risk stratification in the prehospital setting and managing ED patient flow more effectively.

Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting

BACKGROUND

Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland.

METHODS

We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding.

RESULTS

Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment.

CONCLUSIONS

Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time.

"The Health Caregivers Did Not Care about Me after the Loss": Maternal Experiences of Perinatal Loss in the Kumasi Metropolitan Area, Ghana

One of the common undesirable outcomes of pregnancy is perinatal loss. Healthcare systems strive to reduce the incidence of perinatal loss but typically little attention is on the experiences of bereaved mothers following perinatal loss, particularly in low and middle-income countries where such deaths are common. This research explored the lived experiences of mothers with perinatal loss in the Kumasi metropolis, Ghana. A qualitative design was used to explore the experiences of nine (9) bereaved mothers from the Komfo Anokye Teaching Hospital's postnatal ward and the Mother and Baby Unit. Data were collected through face-to-face interviews using a semi-structured interview guide, audio-recorded, and thematically analyzed. One major finding was that mothers restricted mourning their dead babies based on fear of recurrent perinatal loss and traditional beliefs on delayed return to fertility. Mothers blamed healthcare providers for their loss due to their concerns about care received. Gaps in communication flow from healthcare professionals to bereaved mothers were commonly identified as mothers struggled to make meaning of their loss and coped with cultural restrictions and beliefs. Healthcare professionals must explore mothers' concerns and "gut-feelings," and pay attention to their communication needs following perinatal loss.

Digital health understanding and preparedness of medical students: a cross-sectional study

Digitalisation is changing all areas of our daily life. This changing environment requires new competences from physicians in all specialities. This study systematically surveyed the knowledge, attitude, and interests of medical students. These results will help further develop the medical curriculum, as well as increase our understanding of future physicians by other healthcare market players. A web-based survey consisting of four sections was developed: Section one queried demographic data, section two assessed the current digital health knowledge of medical students, section three queried their attitudes about the future impact of digital health in medicine and section four assessed the recommendations medical students have for the medical curriculum in terms of digital health. This survey was distributed to all (11,978) student at all public Austrian medical schools. A total of 8.4% of the medical student population started the survey. At the knowledge self-assessment section, the medical students reached mean of 11.74 points (SD 4.42) out of a possible maximum of 32 (female mean 10.66/ SD 3.87, male mean 13.34/SD 4.50). The attitude section showed that students see digitalisation as a threat, especially with respect to the patient-physician relationship. The curriculum recommendation section showed a high interest for topics related to AI, a per study year increasing interest in impact of digital health in communication, as well as a decreasing interest in robotic related topics. The attitude towards digital health can be described as sceptical. To ensure that future physicians keep pace with this development and fulfil their responsibility towards the society, medical schools need to be more proactive to foster the understanding of medical students that digital health will persistently alter the medical practice.

Patients’ gut feelings seem useful in primary care professionals’ decision making

Background

Family physicians’ diagnostic gut feelings have proved to be valuable. But what about patients’ gut feelings? Research has shown that patients’ gut feelings may contribute to their physicians’ clinical reasoning. Dutch medical tribunals consider patients’ worry useful for doctors’ diagnostic process. However, how general practitioners and other primary care professionals recognize gut feelings of patients and deal with them in their decision making is yet unclear. We aim to explore how primary care professionals perceive patients’ gut feelings and use this information in their decision-making.

Methods

We interviewed 30 Dutch and Belgian primary care professionals, exploring how they recognize and value patients’ gut feelings. We coded all interviews using a descriptive content analysis in an iterative process. Data sufficiency was achieved.

Results

Primary care professionals acknowledged gut feelings in their patients, and most participants found them a useful source of information. Patients’ gut feelings might alert them to possible hidden problems and might provide quicker insight into patients’ perceptions. Primary care professionals listed a whole series of wordings relating to trusting or distrusting the situation or to any changes in normal patterns. A patient’s gut feeling was often a reason for the professionals to explore patients’ worries and to reconsider their own clinical reasoning.

Conclusions

Primary care professionals regularly considered patients’ gut feelings useful, as they might contribute to their clinical reasoning and to a deeper understanding of the patient’s problem. The next step could be to ask patients themselves about their gut feelings and explore their diagnostic value.

Prospective Observational Study on the Prevalence and Diagnostic Value of General Practitioners' Gut Feelings for Cancer and Serious Diseases

BACKGROUND

General practitioners (GPs) have recognized the presence of gut feelings in their diagnostic process. However, little is known about the frequency or determinants of gut feelings or the diagnostic value of gut feelings for cancer and other serious diseases.

OBJECTIVE

To assess the prevalence of gut feelings in general practice, examine their determinants and impact on patient management, and measure their diagnostic value for cancer and other serious diseases.

DESIGN

This prospective observational study was performed using the Gut Feelings Questionnaire (GFQ).

PARTICIPANTS

Participants included 155 GPs and 1487 of their patients, from four Spanish provinces.

MAIN MEASURES

Sociodemographic data from patients and GPs; the reasoning style of GPs; the characteristics of the consultation; the presence and kind of gut feeling; the patient's subsequent contacts with the health system; and new cancer and serious disease diagnoses reported at 2 and 6 months post-consultation.

KEY RESULTS

GPs experienced a gut feeling during 97% of the consultations: a sense of reassurance in 75% of consultations and a sense of alarm in 22% of consultations. A sense of alarm was felt at higher frequency given an older patient, the presence of at least one cancer-associated symptom, or a non-urban setting. GPs took diagnostic action more frequently after a sense of alarm. After 2 months, the sense of alarm had a sensitivity of 59% for cancer and other serious diseases (95% CI 47-71), a specificity of 79% (95% CI 77-82), a positive predictive value of 12% (95% CI 9-16), and a negative predictive value of 98% (95% CI 86-98).

CONCLUSIONS

Gut feelings are consistently present in primary care medicine, and they play a substantial role in a GP's clinical reasoning and timely diagnosis of serious disease. The sense of alarm must be taken seriously and used to support diagnostic evaluation in patients with a new reason for encounter.

Integrating Clinical Signs at Presentation and Clinician's Non-analytical Reasoning in Prediction Models for Serious Bacterial Infection in Febrile Children Presenting to Emergency Department

OBJECTIVE

Development and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's "gut feeling," and "sense of reassurance.

MATERIALS AND METHODS

Febrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's "gut feeling" of something wrong and "sense of reassurance" were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019.

RESULTS

The derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus "gut feeling" and "sense of reassurance." The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683-0.805) in the derivation cohort and 0.692 (95% CI, 0.604-0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727-0.839) and 0.752 (0.674-0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (-0.129; -0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in "low risk," "gray area," and "high risk" for SBI.

CONCLUSION

Both CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables "gut feeling" and "sense of reassurance" in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.

Optical diagnosis of colorectal polyp images using a newly developed computer-aided diagnosis system (CADx) compared with intuitive optical diagnosis

BACKGROUND

Optical diagnosis of colorectal polyps remains challenging. Image-enhancement techniques such as narrow-band imaging and blue-light imaging (BLI) can improve optical diagnosis. We developed and prospectively validated a computer-aided diagnosis system (CADx) using high-definition white-light (HDWL) and BLI images, and compared the system with the optical diagnosis of expert and novice endoscopists.

METHODS

CADx characterized colorectal polyps by exploiting artificial neural networks. Six experts and 13 novices optically diagnosed 60 colorectal polyps based on intuition. After 4 weeks, the same set of images was permuted and optically diagnosed using the BLI Adenoma Serrated International Classification (BASIC).

RESULTS

CADx had a diagnostic accuracy of 88.3 % using HDWL images and 86.7 % using BLI images. The overall diagnostic accuracy combining HDWL and BLI (multimodal imaging) was 95.0 %, which was significantly higher than that of experts (81.7 %, P = 0.03) and novices (66.7 %, P < 0.001). Sensitivity was also higher for CADx (95.6 % vs. 61.1 % and 55.4 %), whereas specificity was higher for experts compared with CADx and novices (95.6 % vs. 93.3 % and 93.2 %). For endoscopists, diagnostic accuracy did not increase when using BASIC, either for experts (intuition 79.5 % vs. BASIC 81.7 %, P = 0.14) or for novices (intuition 66.7 % vs. BASIC 66.5 %, P = 0.95).

CONCLUSION

CADx had a significantly higher diagnostic accuracy than experts and novices for the optical diagnosis of colorectal polyps. Multimodal imaging, incorporating both HDWL and BLI, improved the diagnostic accuracy of CADx. BASIC did not increase the diagnostic accuracy of endoscopists compared with intuitive optical diagnosis.

Gut feelings in obstetrics and midwifery: the role of intuition in deciding when to perform cesarean section during labor

PURPOSE

To describe the role of intuition for maternity care workers in deciding when a cesarean section should be advised during labor.

MATERIAL AND METHODS

Focus group discussions with midwives and gynecologists, and nonparticipating observation at an obstetric ward.

RESULTS

The decision about when to propose a cesarean section during labor is the result of interaction between objective and intuitive factors. Junior delivery ward workers report that they use more analytic reasoning for objective diagnosis of fetal distress, non-progressive labor, macrosomia or other indications for cesarean section; with increasing experience, however, non-analytic reasoning takes the overhand. Both consciously and unconsciously, other activities going on outside the individual delivery room seem to influence the decision. Out of the 50 deliveries observed, 38 births occurred through vaginal deliveries and 12 through cesarean sections. Maternity care workers clearly have "gut feelings" that the course of labor is moving toward a cesarean section. We were unable to detect any predictable pattern in the transition from gut feeling to decision.

CONCLUSION

Intuition plays a still not completely uncovered role in the decision to advise cesarean section during labor. The level of consciousness at which professionals use intuition or gut feeling and are aware of it in decision making is variable. Intuition or gut feelings seem to contribute more to the decision process as the level of experience increases.

Creation of clinical algorithms for decision-making in oncology: an example with dose prescription in radiation oncology

In oncology, decision-making in individual situations is often very complex. To deal with such complexity, people tend to reduce it by relying on their initial intuition. The downside of this intuitive, subjective way of decision-making is that it is prone to cognitive and emotional biases such as overestimating the quality of its judgements or being influenced by one’s current mood. Hence, clinical predictions based on intuition often turn out to be wrong and to be outperformed by statistical predictions. Structuring and objectivizing oncological decision-making may thus overcome some of these issues and have advantages such as avoidance of unwarranted clinical practice variance or error-prevention. Even for uncertain situations with limited medical evidence available or controversies about the best treatment option, structured decision-making approaches like clinical algorithms could outperform intuitive decision-making. However, the idea of such algorithms is not to prescribe the clinician which decision to make nor to abolish medical judgement, but to support physicians in making decisions in a systematic and structured manner. An example for a use-case scenario where such an approach may be feasible is the selection of treatment dose in radiation oncology. In this paper, we will describe how a clinical algorithm for selection of a fractionation scheme for palliative irradiation of bone metastases can be created. We explain which steps in the creation process of a clinical algorithm for supporting decision-making need to be  performed and which challenges and limitations have to be considered.

A Set of Eight Key Questions Helps to Classify Common Vestibular Disorders-Results From the DizzyReg Patient Registry

Precise history taking is the key to develop a first assumption on the diagnosis of vestibular disorders. Particularly in the primary care setting, algorithms are needed, which are based on a small number of questions and variables only to guide appropriate diagnostic decisions. The aim of this study is to identify a set of such key variables that can be used for preliminary classification of the most common vestibular disorders. A four-step approach was implemented to achieve this aim: (1) we conducted an online expert survey to collect variables that are meaningful for medical history taking, (2) we used qualitative content analysis to structure these variables, (3) we identified matching variables of the patient registry of the German Center for Vertigo and Balance Disorders, and (4) we used classification trees to build a classification model based on these identified variables and to analyze if and how these variables contribute to the classification of common vestibular disorders. We included a total of 1,066 patients with seven common vestibular disorders (mean age of 51.1 years, SD = 15.3, 56% female). Functional dizziness was the most frequent diagnosis (32.5%), followed by vestibular migraine (20.2%) and Menière's disease (13.3%). Using classification trees, we identified eight key variables which can differentiate the seven vestibular disorders with an accuracy of almost 50%. The key questions comprised attack duration, rotational vertigo, hearing problems, turning in bed as a trigger, doing sport or heavy household chores as a trigger, age, having problems with walking in the dark, and vomiting. The presented algorithm showed a high-face validity and can be helpful for taking initial medical history in patients with vertigo and dizziness. Further research is required to evaluate if the identified algorithm can be applied in the primary care setting and to evaluate its external validity.

Re-visioning clinical reasoning, or stepping out from the skull

THE PROBLEM

Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts.

A SOLUTION

Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, 'extended' cognition is configured as an outside-in process of 'sensemaking' or 'adaptive expertise'.

THE FUTURE

Current 'predictive processing' cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an 'ecological perception' or 'externalistic' model provides a counter to the current dominant paradigm of 'ego-logical' cognitive reasoning - the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.

The role of dietitian clinical judgement in the nutrition care process within the acute care setting: a qualitative study

BACKGROUND

Dietitian clinical decision making in the acute care setting likely incorporates a practitioner's clinical judgement to effectively support patient care. The term 'dietitian clinical judgement' is well used in clinical practice, yet is poorly defined and often used interchangeably with other concepts. The aim of this research was to describe the nature of dietitians' clinical judgement in the acute care setting.

METHODS

A qualitative design within the interpretative paradigm was used guided by principles of philosophical hermeneutics. Dietitians with at least 3 years experience were invited to participate in two 60-min in-depth semi-structured interviews which were recorded, transcribed and interpreted using hermeneutic principles. A reference group was used to increase rigour and further interpretation of the findings.

RESULTS

Ten dietitians participated in the interviews and five of these same participants in the reference focus group. The findings revealed clinical judgement to be a sophisticated practitioner dependent meta-reasoning process that helps the dietitian manage complexity, guide interpersonal interactions and individualise patient care. It is characterised by tacit and efficient use of various reasoning strategies reliant on the dietitian's clinical experience, used to synthesise and weigh up various types of information and knowledge with respect to delivering context-relevant care.

CONCLUSIONS

Dietitian clinical judgement is a necessary part of clinical decision making that extends beyond logical or critical thinking. It facilitates a person-centredness to patient care and professional relationships that are key dimensions to dietitian clinical decision making. These findings provide training and professional development insights to managers, educators and supervisors.

Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence

BACKGROUND

Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice.

AIM

To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility.

DESIGN AND SETTING

Systematic review and meta-analysis of international research on GPs' gut feelings in primary care.

METHOD

Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings.

RESULTS

Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval.

CONCLUSION

GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers.

Value of parental concern and clinician's gut feeling in recognition of serious bacterial infections: a prospective observational study

Background

Serious bacterial infections (SBI) are a significant cause of mortality worldwide. Parental concern and clinician’s gut feeling that there is something wrong has been associated with increased likelihood of developing SBI in primary care studies. The aim of this study is to assess the diagnostic value of parental concern and gut feeling at the emergency department of a tertiary hospital.

Methods

This prospective observational study included children with fever attending the emergency department of Children’s Clinical University hospital in Riga between October 2017 and July 2018. Data were collected via parental and clinician questionnaires. “Gut feeling” was defined as intuitive feeling that the child may have a serious illness, and “Sense of reassurance” as a feeling that the child has a self-limiting illness. “Parental concern” was defined as impression that this illness is different from previous illnesses. SBI included bacterial meningitis, sepsis, bacteraemia, pneumonia, urinary tract infection, appendicitis, bacterial gastroenteritis, and osteomyelitis. Pearson’s Chi-Squared test or Fisher’s exact test were used to compare the variables between children with and without SBI. Positive likelihood ratio was calculated for “gut feeling”, “sense of reassurance”, and parental concern.

Results

The study included 162 patients aged 2 months to 17.8 years. Forty-six patients were diagnosed with SBI. “Sense of reassurance” expressed by all clinicians was associated with lower likelihood of SBI (positive likelihood ratio 8.8, 95% confidence interval 2.2–34.8). “Gut feeling” was not significantly predictive of the patient being diagnosed with SBI (positive likelihood ratio 3.1, 95% confidence interval 1.9–5.1), The prognostic rule-in value of parental concern was insignificant (positive likelihood ratio 1.4, 95% confidence interval 1.1–1.7).

Conclusion

Sense of reassurance was useful in ruling out SBI. Parental concern was not significantly predictive of SBI.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1591-7) contains supplementary material, which is available to authorized users.