When we are the Diagnostic Test – Gestalt at St Emlyns

Gestalt

There are many reasons why I enjoy being part of the St Emlyn’s team, not least the chance to share ideas and beliefs about EM with some of the most thoughtful physicians I’ve ever met.

Simon’s recent post about Gestalt, has, like many of you, got me thinking. What is that “end of the bed-o-gram” that we place so much value on? How do we know if it is accurate? Can we teach and learn these skills? What are the characteristics of this diagnostic test and can it be relied upon?

Perhaps even more important for me is how we know when our gestalt sensor is slipping, when we are not at our best and when other outside forces are subconsciously altering our own sensitivity and specificity. I, and others, have written at length about the circumstances we all have to work in: the never ending patient load; the overcrowding; the constant worry about making a mistake.

On the amazing trip to Fiji I shared with Nat May, Nick Jenkins and Anne Creaton earlier this year, I accidentally came out with something more profound than my usual witterings (it must have been the Fiji Gold) [Ed – one of my great twitter skills is making you sound smart! – Nat]

Over my comparatively short career as an Emergency Physician I can recollect many occasions when I haven’t quite been at my best as a diagnostic clinician. Usually these pass without incident and unnoticed to me as well as others, but I know there have been times when the extraneous stresses have influenced my decision making and the accuracy of my gestalt. In the #FOAMed world there have been many excellent talks about these “biases” and how we, as clinicians, think. One of the very best comes from Chris Nickson at the first SMACC conference – if you haven’t watched this video yet, you really must. And if you’ve seen it before, you should probably watch it again 🙂

In a busy ED there are many times when I rely on my gut instinct to tell me when something doesn’t fit. It is that hard to define mix that Simon describes so well:

Something about the noise, sight, smell, atmosphere tells you that something is not right. The observations/monitors are either irrelevant or contradictory. You just know…, the outcome is greater than the sum of the perception.

What about when I am tired, hungry and distracted by external stresses: the worry about a family member’s illness; a concern about your child’s school performance; an upcoming birthday where you’ve forgotten to buy a present. The daily burdens of everyday life are sometimes hard to ignore. Add in the large numbers of patients in the ED all vying for your attention and the managerial pressure of a government target and you have a heady mix that inevitably alters your ability not only to sense when the pattern doesn’t fit, but also to find the strength to do something about it.

It is vitally important that we recognise when this is happening to ourselves and those around us. Time constraints demand that we make quick decisions using efficient processes and for many of us that includes an element of gestalt. We must be vigilant and only use this diagnostic test when it is functioning at its best. After all, if you were told your blood gas machine wasn’t calibrated properly and was giving less accurate results you would stop using it until it was back to the expected standard and we must regard ourselves as the same. We are a diagnostic instrument that needs to be cared for with internal checks and balances to recognise when it is not working before it is too late and a fatal error has been made.

There are a few techniques I have developed over the years to try to combat this cognitive fatigue when I recognise it and I would be interested to hear others’ ideas:

  • To avoid distraction when listening to a colleague present a patient I’ll walk with them around corridors of the department, or even go outside into the ambulance bay. This helps me focus my thoughts on what I’m being told and give them my full attention.
  • There are some patients who we instinctively don’t like and I believe our gestalt is affected accordingly. As taught by a senior colleague, Mike Clancy, I spend twice as much time with them and deliberately remove emotion from the consultation (and gestalt is surely affected by emotion), perhaps depending more on objective testing than would normally be my practice.

  • Beware of any patient whom you see near the end of a shift. Reducing the patient load for your colleagues may seem to be a help, but you are not going to be as thorough when the shift clock is against you and handovers of partially completed assessments present a danger of their own. Use the last minutes of your shift wisely.
  • Festive holidays, especially Christmas, can alter our judgement. All our patients would like to be with their loved ones at these times, but serious disease is no respecter of the urge to open presents and eat turkey.
  • Admit to others when you are not at your best. This could be due to a poor nights sleep or a difficult situation outside work, but asking a trusted colleague to keep an eye on you and make sure you decision making is sound can be very reassuring.

Undoubtedly gestalt is a valuable tool in the Emergency Physician’s armoury, but like all diagnostic tests we must only use it when it is functioning at an acceptable level and we have a duty to all to recognise when it is not.

2 Comments

  1. Richard jackson

    This is so good. I recently had a patient that my gut was telling me the diagnosis but my thought processes were contradicting it. I took the wrong option and went with the latter, rather than my gut, at no major detriment to the patient, just my treatment was not as optimal as i would have liked. How do you know when to trust your gut?

    Reply
  2. Alan Grayson

    Thanks Iain.
    Another excellent post with lots to consider and thanks for posting Chris Nickson’s talk. He summarises and elaborates on a dry, but important, topic well, as do you.
    I think the key point you make is to spend more time over (but not necessarily with) the patients that annoy you. The ones with chronic pain, the ones with repeated attendances, the ones whose behaviour is somewhat challenging. Personally I’m a big fan of these being managed by senior doctors. We get paid the big bucks so we should have to suck up the biggest amounts. There’s also attendant benefits in terms of reduced time spent (I’ll spend lees time with a regular than one of my junior medical staff), better patient satisfaction and better resource allocation. A lot of the regular attenders have unmet needs; going in to a consultation with preconceived notions and diagnoses may cloud this.As much as I love what I do, I understand that our waiting room would not be a place that I wanted to spend 4 hours without good reason!

    I also think we owe it to our patients to be the best that we can be when we are on shift. This means rested, hydrated, fed and as minimally distracted as possible. When you are engaged in the cognitive processes that we undertake on a daily basis a 5% drop in performance an be felt across the whole system and the responsibilities that we have, along with the risks that we share, suggest that we should be striving to deliver excellence and that, as Chris talks about, we should try and manage ourselves, our team and environment as best we can. There are many factors outwith our control and that’s why the need to control that which we can is paramount.

    Thanks again mate.

    BW

    AliG

    Reply

Thanks so much for following. Viva la #FOAMed

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