Table 3 Quotes

Defining gut feelings

   a) Where I feel this? Literally in my guts; it's an actual physical sensation, telling me something's wrong. (V1570) I can actually feel my heartbeat start to accelerate. (V1605).

   b) It's the feeling that, in spite of all rational arguments and considerations and weighing up all the information you've obtained from history-taking, physical examination and perhaps some additional diagnostics, there's still this underlying feeling of something not fitting in, something being amiss. I can't really grasp it, or put a name on it, and there are all kinds of arguments to say there's nothing wrong, and yet as a GP you still have this sense, which you could call a sense of alarm, of something being not right. (M1444) But to me, this gut feeling means that you're very soon aware whether something is wrong or not. That's the gut feeling. (N591) Because you see a lot of patients with complaints, and with most of them your gut feeling reassures you there's no serious problem. And then suddenly there's one who's not OK and you get this feeling ... a sort of tingling in your spine. (V1599)

   c) You've got your diagnosis and it all fits and even if they feel very sick you can say you'll be OK in the morning. So you are backed up by a diagnosis that actually helps you. It all fits, so you're reassured, even though the patient feels very sick. (V2008) But in your everyday practice routine, it's often enough to, say, postpone it or to say it's so recent or things are going OK or whatever, so that means you're working in a grey area, without having an actual diagnosis, but a general sense of what direction to go, or this can wait, or I need to see this patient again. So you're in a grey area: there's as yet no clear diagnosis but you still take a decision. That sort of thing. (M0410)

   d) Nine out of ten times, or perhaps even ninety-five out of a hundred times, you're not aware of this sense of reassurance; it's the sense of alarm that you're aware of. (V1215). At a certain moment, it becomes a matter of knowing, this gut feeling of alarm or reassurance, you just know (N0626).

Fitting or alerting factors

   e) I always think: does this presentation fit in, with the complaints, and with what you find in your examination. Do they form a consistent picture or are there aspects that don't fit in? That make you think wait a minute, this isn't right. And how can I look at it differently? That's when you start to look into it further. (H0501).

   f) These people come and, as it were, sing their song. It's usually the same song, but if it changes, that's when you sit up and look at it in a completely different way. (N0385).

Contextual knowlegde and interfering factors

   g) You also have the frame of reference of the family that a patient comes from, which means you notice when they're different or present in an unusual way or they may say well, this time there's really something wrong with me, or perhaps that's precisely what they do not say, whereas they normally do. So there's something different and that has some significance, in light of what you already know about them. (M0438).

   h) When I'm angry like that, my antennae don't work, and that means I'm not being a good doctor to this patient. I'm convinced of that. I really mess up, because my gut feeling no longer works. (N1024).

   i) I think my rational considerations, my lists and all that, are much more valid than my initial intuition. I tend to ignore that. (M0747).

Medical education and experience

   j) It's not what I learned at university; I was taught to work on the basis of lists. (M1296)

   k) And I think you can teach an trainee GP this by saying to them wait a minute, stop thinking of numbers and things like that, what about your feelings? What do your feelings tell you? (V2984).

   l) Your GP training can provide you with a number of 'handles' that can help you develop this feeling. One of these handles is self-reflection. But it's also a matter of personality: if you're not willing to engage in introspection and self-criticism, you won't easily learn these things. (N2177).

   m) The more experienced you are, the more you're able to identify and evaluate the 'noise', and that of course is something I also notice in trainee GPs; they're finding it more difficult, they make less use of the noise than I do. I'm better able to evaluate the importance of the noise and I make better use of it, while they tend to, if they don't understand something they tend to say I don't understand this, so it's probably not important. (M0215).

   Personality

   n) You want to reduce the sense of uncertainty, and personally, my criterion is that I have to be able to sleep quietly at night at any rate; I need to feel I've done the right thing. (M0712). In most cases perhaps you don't know exactly what's going on. But you have a general idea, you have a working diagnosis and I personally don't feel bad about it if that involves a certain degree of uncertainty. (V1314).

   o) You receive a whole stream of information through a whole range of channels, and you tend to immediately draw your conclusion from that, but you have to force yourself not to do so, in order to stay at the right level of rationality. Because I think it's a real pitfall. (M272).

Consequences of a sense of alarm

   p) Those gut feelings of alarm or reassurance, if there's something that makes me worry, that's a feeling that I feel I want do follow up on. They're alarming signals and I need to check them, I need to make sure for myself whether it's something I really need to act upon or whether I can ignore it because it's nothing serious. (N0819). It raises my state of alertness. I tend to literally sit up and start to focus more. (N0412).

   q) Those cases in which I think I have a gut feeling that it's OK, but rational arguments say it's not, I always refer those, on rational arguments, to be on the safe side. And cases where rational arguments say it's OK but my gut feelings say there's something wrong, I also refer, based on my gut feeling. (M0754).

Compass

   r) I had this patient presenting with tightness of the chest, not elicited by exertion, not responding to nitro, nothing in the family history except a younger brother who had some heart complaints at one stage. Apart from that, nothing at all, and yet... He didn't sweat, he seemed very well, and still I had this feeling that I didn't trust the situation. I don't know why... So it turned out he had an inferior wall infarction, and I thought: Yes, I was right! There were no clear indications of an infarction, but I just didn't trust it. And now I won't care if the next four patients I refer turn out to have nothing wrong with them. (M0638)

   s) There's a new patient every ten minutes, right, you have to try and understand the problem presented by a patient, you have to ask questions, have the patient undress, do a physical exam, have the patient put on their clothes again, then discuss your findings, explain what you think it is and then make out a prescription and explain about the therapy or try to reassure them before getting ri... err, before getting them to leave, so to say (laughter). And all of that must be done within ten minutes, as you have thirty or thirty-five patients to see that day. So at a certain point you have to, you really need that gut feeling, or you would never get through your surgery, honestly. If you didn't have that gut feeling, you might as well give up tomorrow, I think. This sense of reassurance or alarm, which brings you to your diagnosis, if you haven't got that and always have to rely only on lists and theoretical knowledge, you'd never make it through surgery hour. (H2089).