Ever had that Gut Instinct of sudden heightened awareness or alarm during the assessment of a person.
It just doesn’t feel right, there’s something wrong, your not exactly sure what it is but you need to do something and make sure you get the answers to the right questions as your worried about this person. The more exposure we encounter in the primary care Musculoskeletal setting the more we will be exposed to these situations and feelings. It isn’t comfortable and can sometimes leave us with a vague understanding where we need adjust our critical thinking to allow us to initiate appropriate work up.
Gut Instinct can be thought of as an intuitive feeling that something is wrong, even if the clinical assessment may be reassuring (Stolperet et al, 2011). The intuition arises in most cases from the clinical history, so asking the right questions and interpreting the context of response from the person is key. Some say intuition is conceptually separate from clinical impression and describe it as a mode of clinical assessment requiring a holistic judgment but necessarily explicable in terms of defined signs and symptoms (McCarthy et al 1987; Berger et al 1996). These intuitive feelings, which are generally defined as thoughts that come to mind without apparent effort, seem to play a role in the diagnostic process of GPs when they have to deal with uncertainty and unpredictability in complex situations in Primary Care (Hull, 1985; Andre et al 2002; Stolper et al 2010; Groopman 2007; Kahneman 2005). The role of intuition in diagnostic reasoning has been extensively investigated in nursing, and results show that intuition as an integral part of nurses decision making and is assumed to be based in expert knowledge (Rew and Barrow 2007; Lee et al 2006; Hams 2000; McCutcheon, 2001; King and Appleton 1997).
The role of intuition in general practice has found that many GPs experience so-called Gut Feelings in their diagnostic reasoning about patients.
Two types of Gut Feelings are described in the research
‘A sense of alarm’ and ‘A sense of reassurance’
The Sense of Alarm implies worry about a patient’s health status, even though there may be no specific indications yet it can be described as the sense of ‘there’s something wrong here.’ It means that there is a need to initiate specific management to prevent serious health problems. In the physiotherapy world this might mean Cauda Equina Syndrome (CES), Cancer, Fracture, Infection, Deteriorating Neurology, Pulmonary Embolism, Deep Vein Thrombosis (DVT), Space Occupying Lesion etc…The Sense of Reassurance means that there’s a feeling of security about the further management and course of a patient’s problem, even though there they may be no certainty about the diagnosis….‘everything fits in’ (Stolper et al, 2009). In relation to a Sense of Reassurance, we could use the example of a person that presents with what you think might be an undiagnosed Axial spondyloarthritis (SpA). We might be reassured that we can organize bloods and appropriate imaging and pending results refer accordingly. There is no immediate danger so we might be reassured that the person could now be on the correct clinical pathway. Gut feelings may provide useful information in the diagnostic reasoning process, prompting further thinking and action. Two approaches have been used to describe the cognitive processes underlying the clinical diagnosis in the form of Medical Decision Making and Medical Problem Solving (Elstein and Schwarz, 2002).
Medical Decision Making
Medical decision-making (MDM) models are concerned with diagnostic reasoning as an opinion revision process. They seem to make use of Bayes’ Theorem, likelihood ratios, prior and posterior odds, thresholds, schemes and decision trees to arrive at the best diagnostic and therapeutic decisions. The MDM literature emphasizes that intuitive hunches may be false and therefore advocates the use of analytical models and decisions aids, as well as the monitoring of intuitive ideas by checking for biases before deciding (Chapman and Sonnenberg; 2000; Sackett 1991, Richardson et al 1999; Pauker and Kassirer, 1980).
Check out a nice blog from Erik Meria on Bayes’ Theorem here
For example, when GPs diagnose a patient with a disease related to but outside of their specialty, they impose their prior knowledge on the situation and interpret the case from their frame of reference, activating other hypotheses. Ideas that first spring to mind determine further thinking and actions, so other relevant information may be ignored or only data confirming the current hypothesis may be considered and sought (Hashem et al, 2003). As physios in the field of MSK, if we haven’t been exposed to conditions outside of MSK can we be expected to draw on pathology knowledge outside of our specialty such as Rheumatology, Neurology, Paediatircs, Orthopaedics or Respiratory in order to formulate a Gut Feeling. If you’ve never experienced those clinical scenarios does that alter the way we may feel when we start to navigate our thought processes. Alarm bells may ring, however it doesnt register on our clinical radar and we navigate to a different location and hit a dead end. Although clinicians might be Bayesians by nature in their diagnostic reasoning, the patient’s history, signs and symptoms represent the most powerful information for updating prior probabilities and it is not a calculation of a running tally of likelihood ratios (Gill et al 2005; Steurer et al 2002; Reid et al 1998).
The assessment of prior probabilities is based on knowledge of patients and clinical experience, and is usually expressed on an ordinal scale from very unlikely to almost certain. Adding evidence to a prior probability instead of multiplying evidence by a prior chance and basing the values needed for use in formulas on subjective evaluations are described in the literature (Van den Ende et al 1994; Kleinmuntz 1990). The power of a diagnostic indicator to confirm or exclude is mostly assessed in terms such as insignificant, weak, good, strong or very strong, and GPs will usually apply their own estimated decision thresholds when deciding whether to wait, initiate further examinations or take action (Hammond et al, 1987). Sackett and colleague (1991) discuss integrating individual clinical expertise with the best available external clinical evidence from systematic research. Scientific knowledge alone may not be a sufficient guide, as based on their expertise and skills clinicians need to acquire and integrate information on the condition of the individual patient, his or her preferences and the best evidence in order to find a balance between analytical reasoning and what has been described as some form of Intuitive Assessment (Haynes et al, 2002; Sackett et al, 1991).
In Advanced Practice we have clinical decision thresholds to consider when we our planning next steps as part of the work up and index of suspicion. The first question I always consider is whether this person is presenting with musculoskeletal pathology and if not ‘Off comes the MSK hat’ and my direction of travel changes to allow me to rule in and rule out what I need from the subjective perspective before confirming it objectively. However, sometimes no objective assessment may be required as the subjective could and in some cases should be enough..!
Medical Problem Solving
Medical Problem Solving regards diagnostic reasoning as a process of generating and testing hypotheses. This process is suggested as not being found to differ between successful and unsuccessful diagnosticians, nor between experts and novices (Elstein and Shulman, 1978; Neufeld et al, 1981). The difference between them arise from the underlying knowledge base that enables experienced GPs, in routine cases, to automatically retrieve the correct diagnostic hypotheses based on only a few relevant signs and symptoms. Knowledge also guides those clinicians in an efficient information search and treatment planning route that looks to direct retrieval of relevant knowledge in an automatic, non- analytical process that, in the case of diagnosis, is often referred to as pattern recognition (Norman et al 2006; Elstein and Schwarz 2002; Hobus et al, 1987).
In Advanced Practice an example might be an OA Hip or Knee with no underlying medical pathology of concern, no red flags and neurologically the patient is intact. They have not responded to first line care which has involved appropriate work up in relation to rehabilitation, lifestyle advice, pain and medicines management. Quality of life is now significantly reduced and radiology confirms significant changes. The context of options with a view to a secondary care referral is on the clinical radar and pattern recognition allows us to retrieve the correct hypotheses based on a few relevant signs, symptoms, objective tests and results. Clinicians immediately understand a patient’s problem in diagnostic terms based on automatic information integration processes such as categorization and problem representation, or on the instant recognition of similarity to a previously seen case stored in memory (Elstein and Schwarz 2002; Norman et al, 2006; Bordage 2000; Norman et al 2008; Hjortdahl 1995).
GPs contextual knowledge has been described as a major diagnostic tool in recognizing disorders. (Patel et al 1996, 1999; Dreyfus 1986). ‘Not feeling right,’ for example, is regarded as the outcome of an implicit monitoring process that may trigger immediate intervention, further thinking or even deliberate learning, depending on the situation (Evans and Frankish, 2005) and ‘Intuition’ maybe explained as the outcome of a highly personalized knowledge-base and non-analytical processes that may help clincians deal with the complexity of the tasks they face (Slovic et al , 2003).
As Advanced Practitioners/ESPs move into First Contact roles and with the introduction of Self Referral our exposure to these complexities will increase. The ability to interpret pattern recognition and move through the critical thinking required during assessment of a simple or complex patient is a day-to-day challenge. There is rarely a purely logical decision as we use a combination of logic and emotion when making decisions of any kind. That specific emotion, innate to us as humans, is intuition. We possess the capacity to feel, and thereby the ability to know things without consciously reasoning. Gut Feeling is one aspect we have to navigate with patients, which should be underpinned by our clinical thought process and experience that looks to confirm or refute our bias as part of an individual or shared clinical decision. Ensure you take the MSK hat off when needed and don’t be afraid to get support when your clinical compass has a taken a wrong turn and the path ahead is unclear. Streamline your questions, be methodical and apply context to the answers and the path will become clearer.
You will see that a lot of this research has come from General Practice and Nursing and hopefully you can see how the context applies to us within the field of MSK, with the rapid progression of Advanced Practice.