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Clinicians' gut feeling about serious infections in children: observational study
Ann Van den Bruel1, Matthew Thompson, Frank Buntinx
1Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK. ann.vandenbruel@phc.ox.ac.uk
Insights
Clinicians' "gut feeling" about a child's illness, even when clinical assessment suggests otherwise, significantly raises the risk of serious infection. Trusting this intuition can help prevent missed diagnoses of serious pediatric illnesses.
Area of Science:
- Pediatric Medicine
- Clinical Decision-Making
- Diagnostic Accuracy
Background:
- Clinicians often rely on intuition or
- gut feeling
- when assessing pediatric patients.
- The basis and clinical value of this intuition in identifying serious infections that may be missed by standard assessment are not well understood.
Purpose of the Study:
- To investigate the origins and clinical significance of clinicians' intuitive judgments regarding the severity of infections in children.
- To determine if this
- gut feeling
- adds value beyond standard clinical assessment in identifying serious pediatric illness.
Main Methods:
- An observational study was conducted in a primary care setting in Flanders, Belgium.
- Data were collected from 3890 children and young people (aged 0-16 years) presenting with infections.
- Presenting features, clinical assessment, clinicians' intuitive responses, and subsequent diagnoses of serious infections were recorded.
Main Results:
- Of 3369 children assessed as non-severe, 6 (0.2%) were later hospitalized for serious infection.
- Clinicians' intuition of a serious illness, despite non-severe clinical assessment, substantially increased the risk (likelihood ratio 25.5).
- Acting on intuition could have prevented 33% of serious cases from being missed, with 1.3% false alarms.
Conclusions:
- A clinician's
- gut feeling
- is an instinctive response to parental concerns and the child's presentation.
- This intuition should prompt further investigation, such as seeking a second opinion.
- Reflecting on the basis of intuition can help clinicians refine their diagnostic skills for serious pediatric infections.
Objective:
To investigate the basis and added value of clinicians' "gut feeling" that infections in children are more serious than suggested by clinical assessment.
Design:
Observational study.
Setting:
Primary care setting, Flanders, Belgium.
Participants:
Consecutive series of 3890 children and young people aged 0-16 years presenting in primary care.
Main Outcome Measures:
Presenting features, clinical assessment, doctors' intuitive response at first contact with children in primary care, and any subsequent diagnosis of serious infection determined from hospital records.
Results:
Of the 3369 children and young people assessed clinically as having a non-severe illness, six (0.2%) were subsequently admitted to hospital with a serious infection. Intuition that something was wrong despite the clinical assessment of non-severe illness substantially increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and acting on this gut feeling had the potential to prevent two of the six cases being missed (33%, 95% confidence interval 4.0% to 100%) at a cost of 44 false alarms (1.3%, 95% confidence interval 0.95% to 1.75%). The clinical features most strongly associated with gut feeling were the children's overall response (drowsiness, no laughing), abnormal breathing, weight loss, and convulsions. The strongest contextual factor was the parents' concern that the illness was different from their previous experience (odds ratio 36.3, 95% confidence interval 12.3 to 107).
Conclusions:
A gut feeling about the seriousness of illness in children is an instinctive response by clinicians to the concerns of the parents and the appearance of the children. It should trigger action such as seeking a second opinion or further investigations. The observed association between intuition and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills.
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