By Ingrid Torjesen
GPs should take into account their “gut feeling” on whether a patient may have cancer when deciding whether to refer them, a study* published in the British Journal of General Practitioners suggests.
Clinician gut feelings are an acknowledged part of clinical decision making but the scientific literature lacks consistency, but this systematic review found that GP gut feelings are predictive of cancer.
Gut feelings are the multiple verbal and non-verbal patient cues picked up by the doctor and seem to be reliant on continuity of care and clinical experience. However, they are often poorly recorded or inaccessible to researchers.
The systematic review included 12 papers and four web resources which described varied conceptualisations of “gut feeling”. 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 odds of a cancer diagnosis was four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94), and “gut feeling” became more predictive of cancer as clinical experience and familiarity with the patient increased.
Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value, the study found. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval.
Brian Nicholson, clinical researcher, Nuffield Department of Primary Care Health Sciences, University of Oxford, said: “We found research that suggests that gut feelings are more effective at identifying people with cancer than the symptoms and signs used in guidelines.
“We wanted to understand what leads to a GP having a gut feeling in case the guidelines could be improved. Our findings emphasise that GPs collect and interpret a large amount of information about their patient in a short period of time.
“Together these pieces of information can lead to a gut feeling that something is wrong. Only some of this information is included in current guidelines.”
Jonathan Leach, honorary secretary of the Royal College of GPs, said: “GPs consider a huge variety of factors when making a patient diagnosis. As well as more obvious physical symptoms, non-verbal cues can often indicate that something is wrong – not necessarily what the patient has made an appointment to speak about. This ‘gut feeling’ or intuition is something that GPs develop by having close, trusting relationships with patients that are often built over time, and isn’t something that should be ignored.
“As this paper suggests, a GP’s ‘gut feeling’ can be useful in identifying potential serious health conditions, such as cancer, even when patients don’t meet the official criteria for referral to specialist care. This is one reason why GPs need some flexibility in being able to refer patients where they are concerned as well as better access to investigations in the community, and the appropriate training to use them, so they can pursue their intuition, and take the results into account when making an informed decision to refer a patient.
This is something that should be considered when looking into the way patients access general practice services in the future, he added, because while remote consultations can be convenient for patients “they can pose challenges for GPs, not least the lack of non-verbal cues that we often use to help us make a diagnosis.”
*Smith CF, Drew S, Ziebland S, et al. Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. British Journal of General Practice. Published: 24 August 2020. DOI: 10.3399/bjgp20X712301
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