Text box 1.

Selection of quotations of supervisors and trainees with examples of gut feelings

Description of gut feelings • It’s a particular feeling that you get, and that you then try to confirm with facts … In my view, gut feelings mean that you make a distinction, you have two people with identical symptoms, and you still think, with one of them, this is suspicious, it’s going to develop into such and such, and with the other you think, it’s OK to wait and see… I’m fascinated to know what exactly that is, and what makes you make a distinction and choose a particular direction. (TD2, trainee) (quotation h) Arising of gut feelings • Is this something that also involves your gut feeling? … That you sometimes think this just doesn’t fit? That it worries you? I mean if someone’s just had a heavy cold, or is known to suffer from Meniere’s disease, or err… that sort of thing, then you’re easier in your mind than if someone gets this kind of acute attack out of the blue. (TD13, supervisor) (quotation i) Explanation of process leading to gut feelings • It’s probably a whole mishmash of information, and that doesn’t immediately fit into a formal flow chart but in your associative memory it sort of tends towards a particular direction, your thoughts move in certain direction so that that is the sense of alarm or reassurance. It’s something that you can start to trust more and more as you become more experienced … I think it relates to having information at several levels and absorbing it at that moment with that specific patient and based on your own experience, perhaps not specifically with this patient but what you have seen with other patients. (TD2, supervisor) (quotation j) When to trust gut feelings • Of course it’s also a matter of gaining experience and continuing to test your hypotheses against the outcome to see whether … how it relates to your sense of alarm or sense of reassurance. (TD2, trainee) (quotation k) • See also quotation j above. Patient information that triggers gut feelings • It’s sometimes very subtle. I mean you’ve got someone whose story makes you think it could be someone with an appendicitis, you examine her, you think, well it could be, but I’m not sure. And then the patient gets up off the examination table and she walks off in a certain way that makes you think I’m going to refer her anyway. And that’s got to do with, well, … her way of walking at that moment … and then you’ve checked it all and it all fits in … So it’s, well, a combination of specific things that you can actually check off, and a kind of general feeling … I guess. (TD2, supervisor) (quotation l) • Actually up until the physical examination I was still thinking it’s not so serious. And then you also left, and you also seemed to think well … it’s an obvious case. And then it turned out when I examined … that she had more complaints than I’d expected. And so I started to ask some other questions, and found some more information … and then I thought, actually, that doesn’t really fit in at all, with kidney stones… And then I thought there might be something else than just kidney stones. It was kind of an unusual story for just kidney stones. (TD4, trainee) (quotation m) • But it was a lady who really had rather an unusual story for someone who’s basically very healthy. (TD12, trainee) You haven’t got a diagnosis, but you have a sense of alarm about this woman, at this age, who’s always in good health. Who doesn’t ever really consult her GP. (TD12, supervisor) (quotation n) • See also the quotations f and g in the main text Role of gut feelings in the diagnostic reasoning and management process • And … errm… you’re saying suppose it all turns out negative… we could of course still decide to wait and see. But I think that wouldn’t quite reassure you. You’d tend to ask a gynaecologist. (TD14, supervisor) (quotation o) • But this diagnostic reasoning. How else could we have, sort of, approached that? (TD4, trainee) I don’t know that it actually went wrong. It’s more that you should be aware of what process [of diagnostic reasoning] are we dealing with? What kind of process are we trying to shape? And then if you look into it, there’s a good chance that it might improve. So just take some time to analyse. Where did that uneasy feeling come from? What makes you need my opinion? (TD4, supervisor) (quotation p) • The only reason why I thought perhaps it should be done sooner, could it be a retrocoecal appendicitis. That was my argumentation, that, well, more should be done. I’ve now referred her for an ultrasound. … But, err, I find it a difficult decision, so that’s why I said, well, if someone develops a fever then it should be evaluated immediately by a surgeon, but that fever had also subsided. (TD16, supervisor) (quotation q) • See also quotation h in the main text

The number provided in brackets after each turn refers to the TD number