Background
Consensus statements | No. | Questionnaire items |
---|---|---|
A ‘sense of reassurance’ means that a family physician feels secure about the further management and course of a patient’s problem, even though he/she may not be certain about the diagnosis: everything fits in. | 1(SR) | I feel confident about my management plan and/or about the outcome: it all adds up. |
A ‘sense of alarm’ implies that a family physician worries about a patient’s health status, even though he/she has found no specific indications yet; it is a sense of ‘there’s something wrong here’. | 2(SA) | I am concerned about this patient’s state of health: something does not add up here. |
A ‘sense of alarm’ activates the diagnostic process by stimulating a family physician to formulate and weigh up working hypotheses that might involve a serious outcome. | 3(SA) | In this particular case, I will formulate provisional hypotheses with potentially serious outcomes and weigh them against each other. |
A ‘sense of alarm’ means that a family physician perceives an uneasy feeling as he/she is concerned about a possible adverse outcome. | 4(SA) | I have an uneasy feeling because I am worried about potentially unfavorable outcomes. |
A ‘sense of alarm’ means that, if possible, the family physician needs to initiate specific management to prevent serious health problems. | 5(SA) | This case requires specific management to prevent any further serious health problems. |
6(SA) | This patient’s situation gives me reason to arrange a follow-up visit sooner than usual or to refer him or her more quickly than usual to a specialist. | |
7(FJ) | Please indicate what kind of gut feeling you had at the end of the consultation: | |
* Something is wrong with this picture. | ||
* Everything fits. | ||
* Impossible to say, or not applicable. |
Methods
Study design
Selection of case vignettes
Case vignette 8 (sense of reassurance) | |
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hi) | Patient is 34 years old and works as a sales assistant in a bakery. She is married with two children. Her medical history is uneventful. She does not smoke and drinks little alcohol. The only medication she is on is Microgynon 30 (oral contraception). No significant matters in the family history. |
sy) | Patient visits her family physician because of a burning sensation she’s had for the last two days when urinating. She also feels pain and itch in her labias. She reports some discharge from the vulva. She was given amoxicillin for a lower airways infection two weeks ago. She has had the same complaints after a previous course of antibiotics, but cannot remember the name of the drug she was given then. |
si) | Patient does not appear ill and has a normal complexion. External gynecological examination shows no abnormalities. There is vaginal discharge which resembles curdled milk. No further abnormalities are visible. Urine test strips for leukocytes, blood and nitrite are negative. |
Case vignette 16 (sense of alarm)
| |
hi) | A 49-year-old woman phones the ‘triagist’ at an out-of-hours medical service at 21:40 h to report pain in her left side which has been increasing over the past 4 days. The pain is linked to her breathing and feels like sore muscles. The pain appears to be episodic to some extent; there are times when it is clearly less severe. The patient does not feel an urge to move. She currently has no pain elsewhere, and has had none during the past few days. Apart from a caesarian section ten years ago, she has no medical history. The only medication the patient is on is oral contraception. She has no known allergies. The triagist decides to invite her to visit the out-of-hours medical service post the same night. |
sy) | As the physician collects her from the waiting room, the pain makes her walk with a stoop and she seems to experience shooting pains with each breath. She occasionally cries out for pain. |
si) | Blood pressure is 128/84 mm Hg, pulse rate 90 a minute, regular and even. Saturation rate is 97%. Auscultation of the heart reveals no abnormalities and the lungs present vesicular breath sounds. A striking feature is the marked local tenderness of the musculature on the left side of the thorax. Calves are supple. A chest X-ray made within the past week shows no abnormalities. The family physician decides to administer an intramuscular injection of diclofenac 75 mg combined with 2 mg diazepam, which seems to be reasonably effective. |
Hypotheses
First general hypothesis, relating to diagnostic characteristics with regard to clear-case vignettes: | |
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The correlation between the reference labels of the clear-case vignettes (i.e. sense of reassurance or sense of alarm) and the answers given by the study population to questionnaire items reflecting a sense of reassurance or a sense of alarm is moderate to high. | |
Specific hypotheses derived from this: | |
a) | Comparing labels: there is a moderate to high correlation and agreement between the reference labels of the clear-case vignettes and the final sense of reassurance or sense of alarm judgment given by the study population (item 7). |
b) | Comparing items of the study population: there is a moderate to high negative correlation between the sense of reassurance item (item 1) and the final sense of reassurance or sense of alarm judgment (item 7) for the clear-case vignettes. There is a moderate to high positive correlation between the sense of alarm items (items 2–6) and the final sense of reassurance or sense of alarm judgment (item 7) for the clear-case vignettes. |
c) | Comparing items of the study population: there are moderate to high negative correlations between the sense of reassurance item (item 1) and the sense of alarm items (items 2–6) for the clear-case vignettes, whereas the intercorrelations between the sense of alarm items (items 2–6) are moderate to high. |
Second general hypothesis, relating to diagnostic characteristics with regard to the ambiguous-case vignettes:
| |
The correlation between the reference labels of the ambiguous-case vignettes (i.e. sense of reassurance or sense of alarm) and the answers given by the study population to items reflecting a sense of reassurance or sense of alarm is weak to absent. | |
Specific hypotheses derived from this: | |
d) | Comparing correlations: there is a weaker correlation between the reference labels of the ambiguous-case vignettes and the final sense of reassurance or sense of alarm judgment (item 7) given by the study population compared to the clear-case vignettes. |
e) | Comparing items of the study population: there is a weak correlation between the sense of reassurance item (item 1) or sense of alarm items (items 2–6) and the reference labels, but a moderate to high correlation between the sense of reassurance or sense of alarm items (items 1–6) and the final sense or reassurance or sense of alarm judgment (item 7). |
Validation study
Statistical analyses
Linguistic validation
Ethical approval
Results
Component matrix | |
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Items | Component |
1 | |
1(SR) | -.722 |
2(SA) | .781 |
3(SA) | .924 |
4(SA) | .893 |
5(SA) | .809 |
6(SA) | .832 |
7(FJ) | .885 |
Items | 1(SR) | 2(SA) | 3(SA) | 4(SA) | 5(SA) | 6(SA) | 7(FJ) |
---|---|---|---|---|---|---|---|
1(SR) | |||||||
2(SA) | -.60 | ||||||
3(SA) | -.52 | .70 | |||||
4(SA) | -.63 | .84 | .68 | ||||
5(SA) | -.45 | .76 | .62 | .67 | |||
6(SA) | -.55 | .73 | .56 | .67 | .65 | ||
7(FJ) | -.60 | .79 | .59 | .77 | .65 | .75 | |
SR/SA label | -.53 | .67 | .55 | .63 | .59 | .62 | .72 |
Items | 1(SR) | 2(SA) | 3(SA) | 4(SA) | 5(SA) | 6(SA) | 7(FJ) |
---|---|---|---|---|---|---|---|
1(SR) | |||||||
2(SA) | -.48 | ||||||
3(SA) | -.49 | .54 | |||||
4(SA) | -.60 | .76 | .56 | ||||
5(SA) | -.33 | .63 | .38 | .41 | |||
6(SA) | -.39 | .73 | .51 | .70 | .52 | ||
7(FJ) | -.54 | .83 | .46 | .76 | .54 | .69 | |
SR/SA label | -.08 | .24 | .05 | .14 | .21 | .20 | .16 |
Case vignette | Reference label | N | Final judgment | ||
---|---|---|---|---|---|
SA | Impossible to say or not applicable | SR | |||
‘Clear-case’ vignettes | |||||
no. 2 | SA | 29 | 25 (86%)
| 2 | 2 |
no. 4 | SA | 31 | 21 (68%) | 8 | 2 |
no. 6 | SA | 32 | 23 (72%)
| 7 | 2 |
no. 10 | SA | 36 | 33 (92%)
| 1 | 2 |
no. 13 | SA | 32 | 26 (81%)
| 3 | 3 |
no. 14 | SA | 30 | 20 (67%)
| 7 | 3 |
no. 16 | SA | 25* | 16 (62%)
| 5 | 4 |
no. 1 | SR | 29 | 1 | 1 | 27 (93%)
|
no. 5 | SR | 31 | 1 | 3 | 27 (87%)
|
no. 8 | SR | 32* | 0 | 0 | 32 (97%)
|
no. 12 | SR | 26 | 10 | 4 | 12 (46%)
|
‘Ambiguous-case’ vignettes | |||||
no. 3 | SA | 30 | 4 (13%)
| 8 | 18 |
no. 7 | SA | 36 | 9 (25%)
| 12 | 15 |
no. 15 | SA | 25 | 19 (76%)
| 4 | 2 |
no. 9 | SR | 35* | 4 | 8 | 23 (64%)
|
no. 11 | SR | 28 | 11 | 6 | 11 (39%)
|