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Commentary on: Van den Bruel A, Thompson M, Buntinx F, et al. Clinicians’ gut feeling about serious infections in children: observational study. BMJ 2012;345:e6144.
With the advent of effective vaccinations, serious infections (SI) have become rare among children presenting to primary care settings, yet when not diagnosed promptly, such infections, especially meningitis and septic shock, can cause substantial morbidity and mortality. Hence, researchers continue to search for new diagnostic methods; the present study by Van den Bruel and colleagues investigates the basis and value of gut feeling or intuition in addition to clinical assessment for diagnosing SI in children.
This is a secondary analysis of a prospective, observational study that enrolled 3890 children aged 0–16 years old presenting to general practitioners or community paediatricians in Flanders, Belgium. ‘Gut feeling’ is defined as a positive response to the statement, ‘something is wrong’.1 Clinical impression is defined as a subjective impression that the illness was serious on the basis of history, observation and clinical examination. Serious infections are defined as the presence of pneumonia, sepsis, viral or bacterial meningitis, pyelonephritis, cellulitis, osteomyelitis or bacterial gastroenteritis warranting hospitalisation for ≥24 h. The statistical analyses include test characteristics such as sensitivity, specificity and likelihood ratios and a multivariable logistic regression analysis to explore the clinical features associated with gut feeling.
Twenty-one of the total 3890 (0.5%) children and 6 of the 3369 children (0.2%) with a clinical impression of a non-severe illness had SI. Among the latter group, a gut feeling that something was wrong had a sensitivity of 33%, LR+ 25.5 and a positive predictive value of 4.4% in detecting SI, whereas the absence of gut feeling led to a reduction in the probability of serious infection to 0.1%, thus providing an absolute risk reduction of 0.1%. The features most strongly associated with gut feeling included parental concern, convulsions and drowsiness.
The study has several limitations: (1) lack of information as to the proportion of eligible patients actually included in the study; (2) no information as to the interval between index case assessment and subsequent hospitalisation among the nine children not referred at first contact (raising the question of whether SI was missed at the index visit or if hospitalisation later was a result of natural progression of the disease); (3) likely differential (higher) ascertainment of SI among subjects with parental concern and gut feeling who were more likely to have been referred to the emergency department or for testing and (4) the study sample has very few outcomes of interest (21 patients with serious infection, and 1 patient with meningitis/sepsis).
Herbert Simon, a leader in cognitive science and a Nobel Prize winner in economics, says this about intuition: ‘The situation has provided a cue; this cue has given the expert access to information stored in memory and the information provides the answer. Intuition is nothing more and nothing less than recognition’.2 An intuition is likely to be valid when it is the result of a skill learnt in an environment that is sufficiently regular to be predictable, and the practitioner has had prolonged practice with high-quality, rapid feedback. Physicians, nurses, firefighters and chess players all face such complex, yet orderly, environments.2 Physicians should therefore value their intuition, and, where concerned, should spend more time elucidating the clinical condition of a patient, and consider referral or investigative work-up. The authors of this study estimate that ‘acting on gut feeling had the potential to prevent two cases of SI being missed, at a cost of 44 false alarms’. It is, however, somewhat artificial to try to separate intuition from full clinical assessment which includes all facets of history (including parental report of the index episode of illness being different from previous episodes) and examination. In this study, intuition was negative in 8 of the 21 (38%) children with serious infection. Although useful, it is prone to cognitive biases like substitution (answering a different but easier question, making up a coherent story where there was none) and availability (eg, whether the physician has recently had or heard about a case of serious infection) when used on its own. Physician gestalt is a related concept referring to the use of holistic rather than atomistic approaches, and that ‘the whole is greater than the sum of its parts’.
As this study also points out, parental concern is increasingly being recognised as a valid tool to prevent harm to children. In many institutions, families are being empowered to ask for escalation of care or a second opinion in case of concern during their child's hospitalisation.
Competing interests None.
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