Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-022724 on 28 January 2019. Downloaded from Role of intuitive knowledge in the diagnostic reasoning of hospital specialists: a focus group study Nydia Van den Brink,1 Birgit Holbrechts,1 Paul L P Brand,2 Erik C F Stolper,1,3 Paul Van Royen3 To cite: Van den Brink N, ABSTRACT Strengths and limitations of this study Holbrechts B, Brand PLP, et al. Background and objective Intuition is an important part Role of intuitive knowledge of human decision-making and can be explained by the ► This is the first study exploring the role of intuition in in the diagnostic reasoning dual-process theory where analytical and non-analytical of hospital specialists: a hospital specialists’ diagnostic reasoning. reasoning processes continually interact. These processes focus group study. BMJ Open ► The study was performed in two European countries. can also be identified in physicians’ diagnostic reasoning. 2019;9:e022724. doi:10.1136/ ► The used qualitative approach enabled the re- The valuable role of intuition, including gut feelings, has bmjopen-2018-022724 searchers to study the views of specialists on the been shown among general practitioners and nurses, but topic and the meanings they attach to the concept. ► Prepublication history for less is known about its role among hospital specialists. ► It was not the aim of the researchers to gather data this paper is available online. This study focused on the diagnostic reasoning of hospital To view these files, please visit for the calculation of predictive values of intuitive specialists, how they value, experience and use intuition. the journal online (http:// dx. doi. hunches such as gut feelings. org/ 10. 1136/ bmjopen- 2018- Design and participants Twenty-eight hospital 022724). specialists in the Netherlands and Belgium participated in six focus groups. The discussions were recorded, Received 7 March 2018 transcribed verbatim and thematically coded. A circular specific form of intuition, as a familiar and Revised 7 December 2018 and iterative analysis was applied until data saturation valuable phenomenon in their diagnostic Accepted 19 December 2018 was achieved. reasoning process.3 In fact, when diagnosing Results Despite initial reservations regarding the term serious infections in children, the GP’s intuition, all participants agreed that intuition plays an feeling ‘there is something wrong’ is the best important role in their diagnostic reasoning process. Many predictor among all signs and symptoms.4 The agreed that intuition could guide them, but were cautious http://bmjopen.bmj.com/ positive role of intuition has also been iden- not to be misguided. They were especially cautious since 5–7 intuition does not have probative force, for example, tified in the domain of nursing. However, in medicolegal situations. ‘On-the-job experience’ was the medical literature does not provide much regarded as a precondition to relying on intuition. Some information about whether hospital special- participants viewed intuition as non-rational and invalid. All ists use intuitive knowledge such as gut feel- participants said that intuitive hunches must be followed ings in their daily practice and how strongly by analytical reasoning. Cultural differences were not they rely on it.8–11 © Author(s) (or their found. Both the doctor as a person and his/her specialty The existing theory on diagnostic reasoning employer(s)) 2019. Re-use were seen as important determinants for using intuition. on September 24, 2021 by guest. Protected copyright. permitted under CC BY-NC. No is the dual-process theory, involving a 1 12 13 commercial re-use. See rights Conclusions Hospital specialists use intuitive elements human decision-making model. This and permissions. Published by in their diagnostic reasoning, in line with general human theory assumes two continually interacting decision-making models. Nevertheless, they appear BMJ. reasoning processes, analytical (AR) and 1 to disagree more on its role and value than previous Faculty of Medicine and non-analytical reasoning (NAR). AR is a Health Sciences, Department research has shown among general practitioners. A better of Primary and Interdisciplinary understanding of how to take advantage of intuition, while deliberate and rational process which is slow Care, University of Antwerp, avoiding pitfalls, and how to develop ‘skilled’ intuition and demanding. NAR is a fast, automatic and Antwerp, Belgium may improve the quality of hospital specialists’ diagnostic effortless process which is described as intui- 2 Department of Pediatrics, reasoning. tive. AR and NAR produce a similar amount Isala Hospitals, Zwolle, The of errors.14 Netherlands 3CAPHRI School for Public Health The present study focused on the intuitive and Primary Care, University INTRODUCTIon aspects of the diagnostic reasoning process of Maastricht, Maastricht, The Intuitive knowledge, that is, automatically of hospital specialists, that is, physicians who Netherlands knowing by intuition, is considered an inte- are working clinically mainly within a hospital gral part of human decision-making and also setting. How do they experience, use and Correspondence to 1 2 Dr Erik C F Stolper; a phase of clinical reasoning. Research value intuition? Which benefits, pitfalls and cf. stolper@ maastrichtuniversity. among European general practitioners (GPs) differences between specialities do exist when nl has shown that they recognise gut feelings, a using intuitive knowledge like gut feelings? Van den Brink N, et al. BMJ Open 2019;9:e022724. doi:10.1136/bmjopen-2018-022724 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-022724 on 28 January 2019. Downloaded from may play a recognisable role.8 After each focus group Box 1 Topic guide session, the script was adapted to elicit more explanations ► Description of non-analytical reasoning, and more specifically intu- or to address other topics in the next groups. ition and gut feelings Audio recordings of all discussions were transcribed ► Interaction between intuition and analytical processes verbatim and checked for errors. Data analysis was initi- ► Balance between intuition and analytical processes ated with open coding. The code books, created by the ► Triggers of intuition Dutch and Flemish researchers, were compared and ► Relying on intuition merged after consensus was reached. Based on these ► Determining factors of intuition primary codes, a common code book was developed, ► Differences between specialties with the following categories: the description of intu- ition, determining factors, specialty, medical education, METHODS gut feelings and others. These categories were created to A qualitative descriptive study design was used, exploring support further coding and analysis of the data. A circular the views of specialists about diagnostic reasoning and and iterative process was applied using cross-analysis of intuitive knowledge, and the meanings they attach to observed recurrent trends and codes. This circular process these concepts.15–17 Data were collected via focus groups, was terminated when data saturation was achieved. The moderated by expert interviewers and two specifically following themes emerged during the final analysis: trained medical students, using a topic guide (box 1). terminology, trust in intuition, the intuitive process, Three focus groups were organised in the Nether- determining factors, differences and similarities between lands and three in Flanders, the Dutch-speaking part specialties, defensive medicine, medical education and of Belgium, among a purposeful sample of 28 hospital differences between the two countries. All data were anal- specialists. The recruited participants were those special- ysed using the NVivo software package. The coding and ists who are the first to see a patient at a hospital (see analysis process was performed separately by the two first table 1). They often make quick assessments of the serious- authors, at that time final year medical students doing a ness of a patient’s situation in which intuitive knowledge research elective, and checked by the two last authors. Patient and public involvement statement Table 1 Participant specifications There were no patients or public involved. Date Location Participants 1 28 Nov 2013 NL 6 ♂: 1 Internal medicine, ♀: 5 paediatrics, RESULTS cardiology, Terminology neurology, All participants recognised that intuitive knowledge was http://bmjopen.bmj.com/ emergency medicine, part of their diagnostic reasoning process (quote 1.1; see pulmonology table 2), but the way they phrased it varied, for example, 2 29 Jan 2014 NL 8 ♂: 2 Cardiology, it is something that just arises in you, or it is like fuzzy ♀: 6 endocrinology, logic. They described intuition as a subconscious and gastroenterology associative process. Several, sometimes vague, terms were and hepatology, used as synonyms, such as feeling, intuition and gut feel- general surgery, infectious diseases, ings (quote 1.2). Some hospital specialists used the term neurology, pattern recognition to indicate intuition (quote 1.3). on September 24, 2021 by guest. Protected copyright. paediatrics, psychiatry Trust in intuition 3 23 Jun 2014 NL 3 ♂: 2 Dermatology, All participants recognised intuitive knowledge in their ♀: 1 nephrology, diagnostic reasoning process, but their views on this neurology concept varied widely. Some specialists said they relied 4 16 Mar 2015 BE 5 ♂: 3 Abdominal surgery, strongly on their intuition, while others