GP gut feeling and cancer risk

What is GP gut feeling?

• General practitioners (GPs) recognize the feeling of sudden heightened awareness or alarm that sometimes emerges during a consultation:
  • ‘There’s something wrong with this patient but I don’t know exactly what. I have to do something because a delay can be harmful.’
  • these intuitive feelings, which are generally defined as thoughts that come to mind without apparent effort, seem to play a role in the diagnostic process of GPs when they have to deal with uncertainty and unpredictability in complex situations (1)
• in cognitive continuum theory, intuition and analysis are defined as two modes of cognition that can be placed at the ends of a continuum, where intuition refers to rapid, unconscious processing and low control, and analysis refers to slow, conscious and controlled processing (1)
• gut feelings in general practice are based on the interaction between patient information and a GP's knowledge and experience. This is visualized in a knowledge-based model of GPs' diagnostic reasoning emphasizing that this complex task combines analytical and non-analytical cognitive processes (1)
• the term ‘gut feeling’ is used interchangeably with ‘intuition’, ‘suspicion’, and ‘instinct' (2)
• a demystifying statement about "intuition" states 'I think intuition isn’t quite the pseudo thing people think it is, I think it’s actually, a combination of having seen lots and lots and lots of cases and you’ve seen lots of scenarios and, and it’s all accumulated in, in your subconscious mind, as well as your conscious mind and, and you, you’re actively drawing on this.' (3)

A systematic review and meta-analysis was undertaken with respect to GPs' gut feelings in the diagnosis of cancer (4):

• twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues
• the pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased
• the review noted that "...Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval."
• the study authors concluded that "...GPs’ gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs’ clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience..."

A diagnostic accuracy review concluded (5):

• gut feeling for cancer when used in symptomatic adult patients in general practice has a relatively low sensitivity and high specificity
• when the prevalence of cancer in the symptomatic population presenting in general practice exceeds 1.15%, the performance of gut feeling reaches the National Institute for Health and Care Excellence 3% positive predictive value threshold for action, which recommends urgent access to specialist care and further investigations
• findings support the continued and expanded use of gut feeling items in referral pathways

Reference:

1. Stolper E, Van de Wiel M, Van Royen P, et al. Gut feelings as a third track in general practitioners’ diagnostic reasoning. J Gen Intern Med 2011; 26(2): 197–203.
2. Stolper E, Van Royen P, Van de Wiel M, et al. Consensus on gut feelings in general practice. BMC Fam Pract 2009; 10: 66.
3. Robinson S. What are the factors influencing GPs in the recognition and referral of suspected lung cancer? [PhD thesis/dissertation]. https://hydra.hull.ac.uk/ resources/hull:13930 (accessed 30 Jul 2020).
4. Friedmann-Smith C et al. Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract 2020; DOI: https://doi.org/10.3399/bjgp20X712301
5. Yao M, Kaneko M, Watson J, et al Gut feeling for the diagnosis of cancer in general practice: a diagnostic accuracy review BMJ Open 2023;13:e068549. doi: 10.1136/bmjopen-2022-068549