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Recent rapid responses
Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.
Displaying 1-10 out of 11 published
16 December 2012
Dear Editor,
We have read with great interest the Rapid Responses to our paper on clinician’s gut feeling for serious infections in children. It is reassuring that many other clinicians acknowledge the existence and utility of this feeling or instinct (Weinberg H, Martin C, Hauser S, John B).
We need to make very clear that we are not saying that clinicians should seek to make a clinical diagnosis through gut-feeling. (Nauta, Sieber et al.). We are recommending that clinicians conduct the most thorough clinical examination they can, including applying any clinical decision rules that have been shown to be diagnostically useful. However, when this thorough examination does not identify serious illness but the clinician is left with a residual gut feeling that something is wrong, our data show that they must not ignore it. Such a residual gut feeling makes it substantially more likely that the clinical assessment is incorrect and the child in question is seriously unwell. Our suggested response in most circumstances is to seek a second opinion.
We disagree strongly with the statement by Cohen that all diagnostic tests are used for both diagnosis and exclusion. In fact, the example given of D-dimer perfectly illustrates that most tests are better at either ruling in or ruling out disease. Throughout the manuscript, we repeatedly state that gut feeling is useful only as a red flag (i.e. for ruling in but not for ruling out serious illness). The diagnostic importance of red flags is widely accepted clinically and recommended in the NICE guideline on management of febrile illness. For example, meningeal irritation is a red-flag diagnostic feature - highly specific but with very low sensitivity. Thus, like gut feeling, the presence of meningeal irritation increases the probability of meningitis but its absence does not make meningitis less likely.
However, we fully agree (and mentioned as a limitation in our paper) that our analysis was post-hoc. We chose to analyse the data with logistic regression because we wanted to investigate the features associated with clinician gut feeling. And in investigating gut-feeling as a possible diagnostic red flag we were conducting a very different type of diagnostic analysis than that reported in our original BJGP paper, where the emphasis was on accurate classification and minimising false negative results (i.e. on maximising sensitivity, not specificity).
Finally, we agree with McCabe that clinicians who have a longstanding relationship with their patients are indeed in a favourable position to assess whether something is wrong. As a consequence, we have restricted our present analyses to children presenting to general practitioners and ambulatory paediatrics, and excluded children presenting to the emergency department, as described in the first paragraph of the methods section. Furthermore, the source population for the present analysis are all 4103 children in our dataset, whether or not they were referred. Regrettably, we mistakenly mentioned 3981 children as our source population in the first sentence of the methods section which is not correct. This explains the apparent discrepancy between these analyses and those reported in the British Journal of General Practice (Sieber et al., Cohen).
Ann Van den Bruel, Matthew Thompson, Frank Buntinx, David Mant
Competing interests: None declared
University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG
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7 December 2012
Dear Editor,
Gut to Brain: The arduous road from intuition to evidence
1. We read with interest the article by Van den Bruel et al(1) on ‘Clinician’s gut feeling about serious infections in children’. Undoubtedly, almost all the clinicians have used ‘Gut feeling’ at some point in their practice. Many times the residents in pediatrics use the phrase, “The child appeared sick and hence antibiotics were started” and this usually starts the perennial discussion on the same gut feeling which may be different for the resident and for a consultant with many years of clinical practice. In fact a typical situation is with febrile seizures in the extremely young(< 18 months) where the pediatrician with sufficient experience may with hold a lumbar puncture vis a vis someone with less experience who would perhaps go ahead with the investigation to rule out meningitis. Another common situation is when we rely on the gut feeling of our experienced critical care nurses and invariably take their opinion into our practice .They seem to rely on a different form of intuition and studies have suggested the use of same in nursing practice(2-4).
2. However, in this current era of evidence based medicine, we should be able convert some of that gut feeling into measurable symptoms or signs, if possible, and avoid missing out on a child with an underlying serious infection. In India and many developing countries, the IMNCI(Integrated management of neonatal and childhood illnesses) algorithm is used to categorize some of the common illnesses and suggests urgent referral if the children get a ‘pink classification’(others being yellow and green).It has been validated and found to be very useful in various studies. It specifically attempts to cover meningitis ,sepsis, pneumonia, diarrhea, fever including malaria and measles (5). The algorithm starts with general danger signs(convulsions ,lethargy, inability to feed or vomiting) and involves inputs from the parent and observations of the child care provider who could be any health worker at the peripheral medical centre and not necessarily a doctor. Another observation with the current approach to a sick child in conventional practice is to look for a ‘medical diagnosis’ rather than an initial detailed assessment of the physiological status. The way forward could be developing appropriate systems or scores which involves appearance, work of breathing, color, airway, breathing ,circulation, disability, exposure etc(modeling on the PALS approach ) and reaching a physiological state rather than a condition diagnosis upfront(6). There are studies which have attempted to evolve scores for screening the serious children and one could always develop better scores where some of the ‘gut feelings’(parental concern, lethargy, poor feeding etc) could be incorporated(7).
3. We tend to agree with the opinion of Matan J Cohen and Graham L Briars in their responses to this study especially regarding the inconsistencies with respect to the data presented in the original study(8) and the current one. In the current study, the authors identify convulsions, lethargy, appearance, pattern of breathing, weight loss and urinary symptoms as significant gut feeling associations. Convulsion is always likely to be a bad predictor and hardly requires a gut feeling. Weight loss is not understood as the illness considered was less than 5 days in duration. Other associations mentioned usually lead to the possible system involved or a diagnosis or at least a cause for concern and need not be necessarily clustered as ‘gut feeling’.
4. The authors themselves agree that teaching the gut feeling to students is difficult and with experience the gut feelings seems to be get incorporated into clinically relevant information .It may be quite relevant with respect to the paramedical staff or nurses who may at times lack the depth of knowledge towards appreciating the disease. In all others, the key therefore seems to be looking into the reasons for evolution of that gut feeling in a given case and pursue the same with repeated observations or investigation or obtaining a second opinion. Future studies should focus on covering this knowledge gap between intuition and measurable evidence and any recommendation lesser than that might be a retrogressive step in the otherwise complex speciality of Pediatrics, the practice of which undoubtedly is a prime example of both an art and a science.
References
1. Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ 2012;345:e6144
2. Hams SP. A gut feeling? Intuition and critical care nursing. Intensive Crit Care Nurs. 2000 Oct;16(5):310-8
3. Smith A. Measuring the use of intuition by registered nurses in clinical practice Nurs Stand 2007 Aug 1-7; 21 (47):35-41.
4. Odell M,Victor C,Oliver D. Nurses’ role in detecting deterioration in ward patients: systematic literature review. Journal of Advanced Nursing 2009;65(10):1992-2006
5. Jain R, Awasthi S, Awasthi A . IMCI approach in tertiary hospitals.Indian J Pediatrics 2009 Jul;76(7):725-7
6. Pediatric Advanced Life Support Provider Manual 2011. Chameides L, Samson RA , Schexnayder SM, Hazinski MR eds. American Heart association
7. Brent AJ, Lakhanpaul M, Thompson M,Collier J, Ray S, Ninis N, Levin M, MacFaul R.. Risk score to stratify children with suspected serious bacterial infection: observational cohort study Arch Dis Child 2011;96: 361–367.
8. Van den Bruel A, Aertgeerts B, Bruyninckx R, Aerts M, Buntinx F. Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care. British Journal of General Practice 2007; 57: 538–546.
Competing interests: None declared
Department Of Pediatrics,Armed Forces Medical College,Pune,India, Department Of Pediatrics
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15 November 2012
Reading the paper by Van den Bruel et al.(1) elicited a intuitive feeling, perhaps even gut feeling, that something in this paper is wrong, or at least not quite right.
Van den Bruel et al. propose that gut feelings of clinicians should not be neglected, even if the clinical impression of the patient/child under their care suggests that there is no serious illness.(1) In the manuscript they present the diagnostic characteristics (sensitivity, specificity and positive likelihood ratio) of having a gut feeling the child has something serious.
Diagnostic tests need to be standardized. Western medicine's scientific framework requires that information be documented in a manner which is understood and reproducible, allowing knowledge to accrue, enabling the community of medical professionals to share a collective experience. This report does not really contribute such knowledge. The authors used a somewhat circular definition to “gut feeling”: “a feeling that something is wrong even if the clinician was not sure why”. The study's working definition is further obscured when we subtract the lower part if table 1 (children in whom clinical impression was of a non-serious illness) from the upper part (all children). This results in 63 children for whom the clinical impression was of a serious illness and the clinician had a gut feeling something was wrong.
Another feature of diagnostic tests is that, in practice, they are used both for diagnosis and for exclusion. The D-dimer test has been repeatedly demonstrated to serve as a rule-out test in patients suspected to be suffering from pulmonary embolism, who have a low a-priory risk of pulmonary embolism. Inappropriate interpretation of a positive D-dimer is all too common.(2,3) Proposing that gut feelings have clinical utility implies that the absence of such feeling also have clinical utility. Again, subtracting the lower part of table 1 from the upper part reveals that the absence of a gut feeling has a specificity of 88% among children in whom the clinical impression was that they do have a serious problem (negative LR 0.3). This result is less attractive and clearly cannot translate into clinical recommendations.
Unlike diagnostic tests, gut feeling can relate to any clinical suspicion. Interestingly, there was no report about gut feelings that non-infectious serious conditions exists – such as child abuse and neglect, developmental disorders and social dysfunction. These are universally known to be under-diagnosed all too often and are far more challenging to objectively diagnose, compared with infectious diseases.
I also wish to stress the points raised by Graham L Briars et al., who provided an earlier rapid response to this paper. In their previous 2007 analysis of this same patient sample, Van den Bruel et al. explicitly detailed the advantages of the CART analysis over the statistical methods they used in the current publication.(4) This inconsistency demands explanation. However, this is the least important problem. As stated by Graham L Briars et al., the current analysis in missing 91 children which were included in the previous report. This analysis is also missing 10 cases of serious illness which were reported in the previous publication, and some of the clinical diagnoses seem to have changed.
The main topic discussed in the current paper was the documentation of a gut feeling and the merits of such a decision/thought/feeling. In the methods section the authors state that doctors were explicitly asked to document intuitive feelings that might arise from the condition of the child or the behavior of the parents. In the previous paper from 2007, the authors stated that doctors were asked to state whether they “thought something was wrong”, again, circularly define with a negative phrase – “a subjective feeling of the physician that things were not right”. Worst of all, in the 2007 paper there were 137 patients among whom there was “a feeling that something was wrong”; however, in the current 2012 paper, there were 120 patients among whom there was a gut feeling something was wrong. I feel that the authors and BMJ should be concerned that these discrepancies exist.
Seeking complete diagnostic accuracy strategies is a Holy Grail quest. We should acknowledge that clinicians are sometimes /often mistaken in their clinical judgment. We should embrace and improve established clinical skills and better communicate what we know and what we do not know with both patients, parents, other doctors and nursing staff. These skills require acquaintance with up-to-date knowledge of the rational medical history taking and clinical examination.(5)
There are, and should be, some unalienable truths in the practice of medicine. They constitute values which, combined, draw an image of what we want medicine to be and how it should be practiced. They are not dependant on evidence which proves or disproves their utility or benefit. Among these are the capability to communicate with patients in compassion and care and an inherent effort to do good for the patient. If our instincts/feeling/intuition tell us that something is wrong with the patient, we should work on that assumption and refer and/or test and/or consult with others – even if we are only following a gut feeling. It is our calling and requires no evidence base.
1. Van den Bruel A, Thompson M, Buntinx F, Mant D.Clinicians’ gut feeling about serious infections in children: observational study. BMJ 2012;345:e6144
2. Jones P, Elangbam B, Williams NR. Inappropriate use and interpretation of D-dimer testing in the emergency department: an unexpected adverse effect of meeting the ‘‘4-h target’’. Emerg Med J 2010;27:43–47. doi:10.1136/emj.2009.075838
3. Yin F, Wilson T, Della Fave A, Larsen M, Yoon J, Nugusie B, Freeland H, Chow RD. Inappropriate Use of D-Dimer Assay and Pulmonary CT Angiography in the Evaluation of Suspected Acute Pulmonary Embolism. Am J Med Qual. 2012 Jan-Feb;27:74-9
4. Van den Bruel A, Aertgeerts B, Bruyninckx R, Aerts M, Buntinx F. Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care. Br J Gen Pract2007;57:538-46.
5. Simel D, Rennie D. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill Professional; 1 edition (August 25, 2008)
Competing interests: None declared
Hadassah-Hebrew University Medical Center, Department of Clinical Microbiology and Infectious Diseases, POB 12000, Ein Kerem campus, Jerusalem 91120, Israel
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7 November 2012
In the current study Van den Bruel, et al. reanalyse the dataset collected in 2004 which formed the basis of a previous publication.1 In that study they used the classification and regression tree (CART) analysis technique to construct a decision tree and aid the primary care clinician in identifying children with serious infections. They determined that a clinician feeling that ‘something is wrong’ was the most prominent predictor of serious infection. This item was therefore at the root node in the decision tree. In the current paper this item is relabelled “gut feeling”. The current logistic regression analysis seeks to identify consultation related variables that are associated with a gut feeling. It uses variables that have been included in the previous analysis and either found to be independent predictors of serious infection or discarded from the decision tree. The post hoc nature of the current paper mandates a cautious interpretation of its findings.
Furthermore we find data reported from the two studies to be inconsistent. The current study excludes 91 of the 3981 patients reported previously. The text suggests that these may be patients recruited from the emergency department, but excluding ED recruits should result in 136 exclusions. It is not clear why any patients have been excluded.
This reduction in study population to 3890 results in the inclusion of only 21 of the 31 children with serious infection reported in the 2007 study. There are 8 fewer children with a confirmed diagnosis of sepsis/meningitis and 6 fewer with pneumonia, but paradoxically one more child with pyelonephritis. Additionally, a case of bacterial lymphangitis is considered a serious infection. This is not included as a serious infection in the published study description.
These data do not sufficiently support the clinical adoption of “gut feeling” as a determinant of the decision to make a referral for hospital admission. The logistic regression analysis reveals seizure to be the clinical variable most highly associated with gut feeling. In a population of children who did not have “neurological illness” or an “exacerbation of a chronic condition”, patients presenting with seizure in the course of “an acute illness for a maximum of 5 days” duration should be suspected of having serious illness through deduction rather than gut feeling. The clinician who has a ‘gut feeling’ of serious illness should also be aware of all the symptoms and signs of potential serious illness elicited in that child. Thus ‘gut feeling’ is not independent of this awareness. The conflation in the study design of “gut feeling” suspicion with clinical assessment suspicion of serious infection limits the ability of the study to detect the determinants of gut feeling.
In assessing severity of children’s illness, we prefer to use objective severity scoring systems2 that can be used by all (medical, paramedical and nursing) members of the clinical team. There are a number of such scoring systems, primarily developed to alert the team to a deteriorating child, under observation in a clinical setting. However further developments using combinations of vital signs can give ‘one off’ assessments with 95% sensitivity for ‘serious or intermediate’ infection.3 We would advocate the modification for primary care of such hospital based scoring systems as a useful adjunct to standard clinical assessment. They would have the advantage over gut feeling that they are auditable and could therefore be part of a continuous process of quality improvement.
Sieber CR, Upton CJ, Armon K, Briars GL
1. Van den Bruel A, Aertgeerts B, Bruyninckx R, Aerts M, Buntinx F. Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care. Br. J. Gen. Pract. Jul 2007;57(540):538-546.
2. Edwards ED, Powell CV, Mason BW, Oliver A. Prospective cohort study to test the predictability of the Cardiff and Vale paediatric early warning system. Arch. Dis. Child. Aug 2009;94(8):602-606.
3. Thompson M, Coad N, Harnden A, Mayon-White R, Perera R, Mant D. How well do vital signs identify children with serious infections in paediatric emergency care? Arch. Dis. Child. Nov 2009;94(11):888-893.
Competing interests: None declared
Norfolk & Norwich University Hospital, Colney Lane, Norwich NR4 7UY
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19 October 2012
A clinician's gut feeling should be acknowledged as such - an instant initial overall impression. This should be added to the subsequent data collected at history and examination (and possibly investigation findings) to arrive at a provisional diagnosis. The question is how much weight to place on this initial impression - and this study suggests that quite a lot of weight should be.
There is no substitute for experience and this is especially important for the group of children who present to an emergency department and are neither well nor critically unwell. In these children (the vast majority of febrile children) the initial gut reaction in an experienced practitioner can answer the questions: admit versus send home?; treat immediately versus investigate further and treat less urgently?
Medical students and junior medical staff should thus be encouraged to seek exposure to as many patients at initial presentation as possible to build up this experience.
Competing interests: None declared
The Northern Hospital, 185 Cooper Street, Epping Victoria 3076 Australia
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+18 October 2012
'Gut feelings' is a term which diminishes the sophisticated pattern recognition techniques that humans possess and can develop further with training.
We, as homo-sapiens, have evolved to be highly sensitive to changes in the health of our offspring, as a survival mechanism. This phenomenon is not unique to humans, and could be recognized as being a part of our broader tacit knowledge. (1)
Our tacit knowledge based on pattern recognition, can be enhanced by greater sensitization and experience. Explicit knowledge is the codified knowledge in medical information and scientific learnings, which can validate and clarify the nature of childhood illness. Medical training and litigation has greatly emphasized explicit knowledge.
Yet in the timely diagnosis of acute serious illness, our patients benefit firstly from the rapid pattern recognition of their state and our ability to respond appropriately with imperfect knowledge. Recognizing instability and acuity of the health state of a patient is a highly valuable skill.
Daniel Kahneman, referred to by one of the rapid responders, criticizes superficial ‘gut reactions’ as fast thinking and recommends that we constantly challenge these prompts to action with knowledge and reasoning.
It is imperative that, innate pattern recognition abilities and tacit knowledge about identifying illness should not fall into his category of ‘gut reaction’. Slow thinking or reflective practice as know it in our discipline; certainly does contribute to our preparedness for and implementation of such responses. Not all fast thinking is the same, as is demonstrated by this article.
We do ourselves a disservice as physicians, is we do not reflect upon and enhance our abilities to rapidly recognize patterns of serious illness, and continue to improve how we do so.
1. Sturmberg JP, Martin CM. Knowing--in medicine. J Eval Clin Pract. 2008;14(5):767-70.
Competing interests: None declared
Visiting Academic, Associate Professor, Trinity College, Dublin , O'Reilly Institute, College Green, Dublin 2,
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+10 October 2012
Van den Bruel, Thompson, Buntinx and Mant (2012) draw on a sample of young people presenting in primary care and discuss clinicians’ gut feelings about the severity of their infections. We note that there does not appear to have been any consideration given to potential clustering in the data; i.e. no indication is given of the number of clinicians who provided the clinical impressions or gut feelings. We expect that ratings made by one individual may have more in common with other ratings made by this individual compared with ratings made by other individuals.Unless every patient was rated by a different clinician, thus creating independent observations, this omission is likely to be of importance given that there were systematic differences between clinicians in terms of their likelihood of experiencing a gut feeling (more experienced clinicians were significantly less likely to experience a gut feeling).
Multilevel modelling approaches allow the hierarchical structure of data to be taken into account and would appear to represent an improvement over logistic regression analysis in the current context (see e.g., Goldstein, 2011; Snijders & Boskjer, 2012). As illustrated by LaHuis and Avis (2007), an advantage of multilevel modelling is that it allows consideration to be given to how attributes of raters influence their ratings while also taking into account characteristics of those rated. There is a substantial body of evidence highlighting the perils of not accounting for a hierarchical data structure when this is present (e.g Goldstein, 1997).
The following gives an indication of how a multilevel model might be implemented in the work of Van den Bruel et al. Patients can be considered to represent the first level of interest and clinicians the second. (The clinic in which the clinician works might be considered to represent a third level.) The outcome of interest is for each patient, whether or not the clinician had a gut feeling of serious illness. Also, for each patient, there is information about his/her presenting symptoms, his/her overall appearance, parental concern, and findings from a clinical examination; these represent possible explanatory variables at Level 1. For each clinician, information is available on his/her experience as a doctor; this represents a possible explanatory variable at level 2. A flexibility of multilevel modelling is that each clinician may have seen varying numbers of children.
To conclude, there is a substantial body of research evidence demonstrating the importance of taking into account the clusters which may exist in data. Multilevel modelling offers one approach to dealing with such clustering.
Goldstein, H. (1997). Methods in school effectiveness research. School Effectiveness and School Improvement, 8, 369-395.
Goldstein, H. (2011). Multilevel statistical models (4th ed). Chichester: Wiley. DOI: 10.1002/9780470973394.
Lahuis, D. M. & Avis, J. M. (2007). Using multilevel random coefficient modelling to investigate rater effects in performance ratings. Organizational Research Methods, 10, 97-107. DOI: 10.1177/1094428106289394.
Snijders, T. A. B., & Bosker, R. J. (2012). Multilevel analysis: An introduction to basic and advanced multilevel modelling (2nd ed). London: Sage.
Van den Bruel, A., Thompson, M. Buntinx, F., Mant, D. (2012). Clinicians’ gut feeling about serious infections in children: observational study. British Medical Journal, 345:e6144. DOI: http://dx.doi.org/10.1136/bmj.e6144.
Competing interests: None declared
Liverpool Hope University, Faculty of Education, Liverpool Hope University, Hope Park, Liverpool, L16 9JD.
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+8 October 2012
Being a MD as well as a psychologist I am very surprised by this article. ‘Gut feelings’ are not made explicit in this article. Having read Kahneman’s ’Thinking fast and slow’ I recommend the authors to read about system 1 and system 2. In system 1 (very fast) there are experience and anxieties and prejudices (so gut feelings may form a part of this system). System 2 is the cognitive way of thinking and deciding, it is slower but much more reliable.
I would never recommend doctors to rely solely on system 1, which is very fast but also very unreliable. Maybe there is something of system 2 in the gut feelings the authors studied, but please make this explicit.
Using intuition of doctors (gut feelings and experience) may be a good choice, but let us find out the parts of this intuition that can help to teach medical students (and doctors) to become better doctors.
Competing interests: None declared
free lance, 31 Timorstraat , 2612 EH Delft, The Netherlands
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6 October 2012
Clinician’s gut feeling about serious infections in children.
Apart from my comments, my congratulations for this very interesting study of Ann Van den Bruel in primary care.
The strongest contextual factor - the concern that the illness was different from the parents’ previous experience’- remains somewhat confusing because a concern defined as experience is mostly limited to the past whereas concerns are mostly about the fear of a current or possible future life-threatening diagnosis or illness. Further, the authors will agree that ‘different from previous experience’ is more difficult for very young children who were not yet ill before.
In the methods, we found no information about how the mentioned concern was expressed by the doctor or patient. It seems likely that without spontaneous expression by the patient or parent, unveiling is only possible when the doctor explicitly asks ‘Are you concerned about something‘ and/or 'What are you concerned about?’ (Concerns about a diagnosis or therapy)
In that sense the concept used by the authors is not in agreement with the ICE rule which was originally introduced in Great Britain by David Pendleton (1). In the ICE acronym I states for ideas, C for concerns, and E for the expectations of patients. The ICE acronym is used in medical education in a lot of countries and acts as a patient-centered technique to explicitly voicing the reason(s) for encounter. (2,3)
We know that there are two kinds of ICE: the ICE of the patient and the ICE of the doctor. In fact, we need to know more about the concordance between concern of patient (or parent) and doctor and its relation with clinical features. For example, non-concordance in concerns with serious clinical symptoms and without utterance of the concerns by the parents, can sometimes be explained by sleep deprivation and fatigue of the parent(s) of a very ill child.
1. Pendleton D, Schofield T, Tate P, et al. The new consultation. Developing doctor–patient communication. Oxford: Oxford University Press, 2003.
2. Matthys J, Elwyn G, Van Nuland M, Van Maele G, De Sutter A, De Meyere M, Deveugele M. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract. 2009;59:29-36.
3. Silverman J, Kurtz S, Draper J. Skills for communicating with patients. Oxford: Radcliffe Medical Press, 1998.
Competing interests: None declared
University of Ghent, De Pintelaan 185, 9000 Gent, Belgium
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+29 September 2012
I don't call it "gut feeling" - I call it experience. The great advantage we have as GPs (which our hospital colleagues don't have) is that we often know our patients inside out and can tell when something is "not right". As far as children are concerned we are right to be over cautious - they are often less informative than adults, better at "compensating" when seriously ill and so on.
However, what reassures me about this paper is that GPs diagnosing a child as non-serious infection are getting it right 99.8% of the time. Show me any other system that depends on human judgement that is less fallible than that.
Competing interests: None declared
., Portree Medical Centre
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