Gut feeling - is the child sick?

Natasha Lee, University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0SP

A study was recently carried out across general practices in Belgium [1]. It aimed to evaluate the added value of gut feeling to diagnosing serious infections when clinical impression suggested otherwise. Out of 3369 clinically non-severe cases, six were eventually diagnosed with serious infections. In two of the six cases (33%) the clinicians had initially had a bad gut feeling. In the 3363 cases that were eventually diagnosed with non-serious illnesses, there were 44 (1.3%) false alarms from intuitive feelings. The use of gut feeling in clinically non-serious cases had a high specificity of 98.6% and negative predictive value of 99.9%, meaning that a child is unlikely to be seriously ill when a bad gut feeling is absent. The sensitivity and positive predictive value however are much lower (33.3% and 4.4% respectively). Gut feelings were most influenced by a history of convulsion and parental concern. Doctors’ experience has insignificant effect on the use of gut feelings.

The paper has aroused much interest amongst clinicians but there are also criticisms that this paper is a re-analysis of their 2007 data [2]. It is unclear which children were excluded from the old study and why [3]. Also it is not clear how many clinicians were involved in the study [4]. Others have questioned whether gut feelings could truly be an independent entity from clinical assessment [3]. It might have been useful to have the same patients assessed by at least two independent doctors to shed light on the reproducibility of gut feelings. Overall, only a small absolute number of cases was saved by gut feelings, so it is difficult to generalise the results to other settings. It is doubtful if gut feeling can be used as a standardised diagnostic test [5].

Nevertheless, it is probably wise not to ignore the authors’ emphasis on this long established practice of safe medicine – ‘gut feeling that something is wrong should make three things mandatory: the carrying out of a full and careful examination, seeking advice from more experienced clinicians (by referral if necessary), and providing the parent with carefully worded advice to act as a “safety net”’ [1].

References: 

References:
1. Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians' gut feeling about serious infections in children: observational study. BMJ. 2012, epub ahead of print, available online doi:10.1136/bmj.e6144
2. Van den Bruel A, Aertgeerts B, Bruyninckx R, Aerts M, Buntinx F. Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care. Br J Gen Pract. 2007 Jul;57(540):538-46.
3. Briars G. Re: Clinicians’ gut feeling about serious infections in children: observational study. [updated 2012 Nov 7]; Available online
4. Gilleece L. Re: Clinicians’ gut feeling about serious infections in children: observational study. [updated 2012 Oct 10]; Available online
5. Cohen M. Re: Clinicians’ gut feeling about serious infections in children: observational study. [updated 2012 Nov 15]; Available online

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