Background
Acute cough with respiratory tract infection (RTI) in children is the most common problem managed by health services internationally [
1,
2]. While the majority of childhood RTIs are self-limiting, a small number result in serious illness and hospitalisation [
3]. Clinicians report that uncertainty regarding both the diagnosis and prognosis of some children with RTIs are important drivers of antibiotic prescribing, [
4‐
6] contributing to over-prescribing [
7] and antimicrobial resistance [
8]. Knowing the prognosis of children presenting to primary care with acute RTIs can be challenging as clinicians cannot always be certain where in the illness trajectory the child has presented, and whether red flag symptoms and signs are absent or are yet to develop. In cases where there is uncertainty, clinical intuition or ‘gut feeling’ is thought to play a part in management decisions.
The current literature offers two definitions of clinician gut feeling. Both propose it arises when the clinician feels uncertain or has a low ‘feeling of rightness’, [
9,
10] and both have been shown to influence management decisions [
11]. In some studies, a comparison has been made between a sense of reassurance versus a feeling that ‘something is wrong’ which defines a broad set of cases where clinicians are worried [
11]. In others, authors define a gut feeling as a sense of dissonance between intuitive and analytic reasoning; a gut feeling something is wrong despite a lack of clinical markers [
9]. The latter definition draws on theories of clinical reasoning distinguishing between “intuitive” processing, which is rapid and unconscious and “analytic” processing that involves slow deliberative reasoning [
12‐
14].
In primary care, gut feeling has been described as an incorporation of clinician knowledge, experience and information about the patient [
9]. In the case of childhood RTI, clinicians report using immediately apparent symptoms and signs (the child’s energy, pallor and breathing) to distinguish severe from non-severe cases, using pattern recognition and drawing on past experience [
5]. A recent study in children with any acute illness, found that: general appearance, breathing pattern, weight loss, history of convulsions and parental concern that the illness was different from any previously experienced predicted the feeling something was wrong when clinical impression was of non-serious illness [
15]. This evidence goes some way to characterising the factors influencing clinical gut feeling, but does not identify the specific clinical features associated with particular illnesses, or provide objective assessments of illness severity.
Despite qualitative studies indicating the importance of clinician intuition for primary care doctors and in nursing, [
16] there is a paucity of quantitative evidence regarding the prognostic value of gut feelings and whether primary care clinicians utilise them in their decision making. A systematic review suggested that gut feeling in itself should be viewed as a ‘diagnostic red flag’ and that it had greater diagnostic value than the majority of illness specific symptoms and signs [
17]. Another study indicated that in situations where there was uncertainty after clinical assessment, gut feeling was highly predictive of serious infective illness [
15].
We used a large prospective cohort study of children presenting to primary care with acute cough and RTI to address three objectives regarding ‘gut feeling that something is wrong’ (from here on ‘gut feeling’): (i) to describe the clinician and child characteristics that drive clinician to have a gut feeling that something is wrong; (ii) to investigate if gut feeling influences management decisions; and (iii) to evaluate the prognostic value of gut feeling in relation to primary care reconsultations with evidence of illness deterioration, and hospital admissions.
Acknowledgements
The National Institute for Health Research funds the Programme Grant for Applied Research TARGET Programme grant at the University of Bristol and NHS Bristol Clinical Commissioning Group.
This paper summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0608-10018). HC is supported by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Evaluation of Interventions at the University of Bristol, in partnership with Public Health England (PHE). ADH is funded by NIHR Research Professorship (NIHR-RP-02-12-012). NMR’s time is supported by the NIHR Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West) at University Hospitals Bristol NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, and the Department of Health of Public Health England.
The authors are extremely grateful to the children, parents/carers and families who have participated in the study, all GP practices including recruiting clinicians, administrative and research contacts and all other staff whose participation made this study possible. We thank all our colleagues from the TARGET Programme, the TARGET Programme Management Group and the TARGET Programme Steering Committee (Sandra Eldridge, Nick Francis, Joe Kai, Victoria Senior, Anna Thursby-Pelham, Mireille Williams) for their time, expertise and support. We are grateful to the following individuals who have helped with the study; James Austin, Denis Baird, Tony Beard, Stephen Beckett, Issy Bray, Peter Brindle, Kate Brooks, Sue Broomfield, Joanna Cordell, Judy Cordell, Tania Crabb, Hazel Crabb-Wyke, Mike Crawford, Julie Cunningham, Christina Currie, Rachel Davies, Elizabeth Derodra, Elena Domenech, Stevo Durbaba, Lucy Feather, Caroline Footer, Emily Gale, Anna Gilbertson, Victoria Hardy, Rose Hawkins, Abigail Hay, Lisa Hird, Sandra Hollinghurst, Julie Hooper, Jonathan Hubb, Catherine Jameson, Grania Jenkins, Amy Jepps, Mari-Rose Kennedy, Michael Lawton, Mel Lewcock, Lyn Liddiard, Sandra Mulligan, Sharen O’Keefe, Lucy O’Reilly, Marilyn Peters, Aled Picton, Ilaria Pinna, Fiona Redmond, Isabel Richards, Kim Roden, Sharon Salt, Douglas Shedden, Ella Simmonds, Sue Smith, Carol Stanton, Kate Taylor, Elizabeth Thomas, Nicki Thorne, Sara Tonge, Abby Waterhouse, Eleanor Woodward. The TARGET study team acknowledges the support of the National Institute for Health Research, through the Comprehensive Clinical Research Network. To Robert Ross from the Department of Psychology at the Royal Holloway who advised on the dual process theory of clinical reasoning. Also to George Leckie, from the multi-level modelling centre at Bristol University who advised on statistical methods.