The GLANCE study: Exploring the role, use, and utility of General Practitioners’ gut feelings for cancer and serious disease in primary care.

Problem

Gut feelings (GFs), often described as a sense of alarm or reassurance for a patient’s health are increasingly accepted as a component of clinical reasoning in primary care. They remain contentious, however, due to concerns over their subjectivity and difficulties in rationalising, articulating, and incorporating them into clinical guidance. Our objective was to summarise the literature on GF, explore the views of GPs and patients about GF in primary care, and establish their diagnostic utility.

Approach

GLANCE is a mixed methods study incorporating three sub-studies: a systematic review and meta-analysis of literature published to July 2019; qualitative interviews with 40 GPs and patients who had used an urgent referral pathway for non-specific symptoms that includes the option to refer based on GP GF; and a quantitative analysis assessing the diagnostic utility of GPs’ GFs for cancer and serious disease.

Findings

Twelve papers and four web resources were included in the systematic review. GPs conceptualised GF as suspicion that grew out of unease not necessarily based on clinical evidence which could lead to difficulties acting on them. GFs were often related to the patient being “unwell” and rarely experienced in the absence of symptoms or non-verbal cues. The pooled odds of cancer diagnosis were four times higher when GFs were recorded (OR 4.24 (95% CI 2.26 to 7.94)), and GFs became more predictive with increasing clinical experience and familiarity with the patient. Results from the interviews suggest GPs and patients support the use of GFs in primary care and see them as a manifestation of clinician expertise combined with patient knowledge. GPs described that GFs arise when there is a lack of fit between the clinical scenario and the diagnostic ‘box’ that they would usually place a similar set of signs and symptoms. Patients acknowledged the uncertainty of clinical practice in primary care and felt that GFs are an important diagnostic tool. When experiencing their own GFs, patients made them more ‘doctorable’ by focusing on clinical aspects of their ailment rather than relying on their own judgement of their illness. Quantitative analysis of the diagnostic value of GFs is underway and will be complete by the conference.

Consequences

This is the first study that has discussed GFs with both clinicians and patients, and in which participants have either been referred, or made a referral, based on a GP's GF. What seems clear is that GFs provide a way for patients to be referred who do not meet strict referral criteria, perhaps highlighting the limits of the evidence base informing current clinical guidance. The completion of the quantitative analysis will provide further insight into the predictive value of GFs for cancer and serious disease in primary care.