If you’re a #FOAMed fan then you will have come across the term Gestalt quite a lot in recent months. Many conversations about clinical decisions hinge around this elusive, slippery and somewhat obscure term. Perhaps it is in a rather circular manner something that is difficult to define, yet we know it when we see it….., or perhaps we are merely using the wrong term.
This very brief introduction is a start on a number of future posts linking perception, interpretation, judgement and clinical decision making.
So for starters, do you agree with Linda?
Why has the word "gestalt" suddenly started popping up more and more?
— Linda Dykes (@mmbangor) June 28, 2014
It’s time to find out.
What does Gestalt mean?
Originally Gestalt means ‘shape or form’. It’s a German term that has come to be associated with a theory of perception and understanding.
Where does the term come from?
Gestalt originated in the psychological literature towards the beginning of the last century. It was a counter to the structuralist arguments promoted towards the end of the 19th Century. Structuralist approaches suggest that everything can be broken down into individual components, thus by knowing the nature of constituent parts we can understand the whole. For example a structuralist approach would suggest that by understanding all the aspects of automotive engineering we can understand what a car is. Gestalt would argue that we perceive a car as a whole and not as components. Gestalt states that our minds organise information to a global perception rather than by assessing each individual element, in other words ‘The whole is greater than the sum of its parts’.
Properties in Gestalt systems
Much of the literature around gestalt focuses on visual perceptions and there are several examples around that you may be familiar with. There are four properties in gestalt systems, emergence, reification, invariance and multistability.
Emergence is the phenomena where a complex pattern emerges from simpler forms. Perhaps the best known example of this is the following picture of a Dalmation dog. There is clearly no picture of dog here, but our minds are able to form the final image from the component parts. None of the components in itself is dog like, yet the sum of the image gives a dog sniffing the ground
Reification is the process by where we construct spacial relationships from elements outwith those presented to use. Several examples are shown below where geometrical objects are perceived by the relationship with the components presented, yet they do not actually exist.
Multistability takes place when we can perceive an object in a variety of different ways and its a common visual puzzle that you will be familiar with. Examples below include the Necker cube and the Rubin vase, but there are many others.
Invariance is the property whereby objects are perceived as the same despite differences in relative shape, size, rotation scale or aspect. Similarly we perceive the same shape regardless of environmental effects such as setting, time of day, location etc.
Most work in Gestalt has focused on the visual aspects of perception but it can be recognised in other senses such as through the interpretation of sound and music.
Do such visual elements of Gestalt exist in medicine?
Arguably they do. We build towards a diagnosis from elements of its form rather than an entire picture or a consistent form. Diagnoses emerge from individual components that we bring together to a ‘form’ that we recognise and subsequently label (emergence/reification). We are often faced with constelleations of symptoms and signs that may represent one condition or another, for example in that breathless COPD/IHD/Pneumonic patient in resus (multistability), and few patients are precisely the same yet we manage to make a similar diagnosis (invariance).
How do we use it medicine?
We seem to use it a lot. Gestalt is often thought to be similar to ‘clinical judgement’, though we need to think that through a little more deeply later. It is referred to in conversations between clinicians and also appears in a number of clinical decision rules.
— Linda Dykes (@mmbangor) June 28, 2014
— brian burns (@HawkmoonHEMS) June 28, 2014
— Matthew Zimny (@NodakEM) June 28, 2014
Several clinical decision rules appear to encompass Gestalt. For example the PERC rule is designed to be used in a population that the clinician believes to be low risk, it then goes on to list a number of other tangible features that also determine low risk. So, if the objective measures are evidence of low risk, what then is the original perception of the treating clinician that this is a low risk patient. Similarly in the Wells DVT score we assign a score of -2 for patients in whom we feel an alternative diagnosis is likely. This soft perception on the part of the clinician is again arguably embracing Gestalt within a scoring system.
If we are looking for a simple definition of Gestalt then we can simply consider it to be a sensory interpretation that is greater than the sum of its parts (a concept which predates Gestalt and which dates back to Aristotle). In clinical terms we can define it thus: ‘A structure, configuration, or pattern of physiological, biological or psychological phenomena so integrated as to constitute a functional unit with properties not derivable by summation of its parts.’
So what might this mean in real terms. Well, I often use the silly walks example. You are walking through resus and you walk past bed 1, bed 2, bed 3, then suddenly turn on your heels and return to bed 2. Something is up…, but you not sure what. 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.
We also use Gestalt daily in the interpretation of ECGs in the ED. Whilst we may teach an atomistic approach to our medical students. Calculate the rate, rhythm, size, relationship etc. as experienced clinicians we do not do this at all. A simple observation of a cardiologist or emergency physician reading an ECG is an example of heuristics, gestalt and judgement over a constructivist approach to data interpretation. Only when pattern recognition and gestalt fails do experts resort to systematic enquiry. There are many, many other examples within our practice that both help and hinder us as clinicians, but what is not in doubt is the importance to clinical decision making inherent within the realms of perception, interpretation and judgement.
Gestalt and the immeasurably measurable.
If Gestalt is truly greater than the sum of its constituent parts then this can only be the case where all parts are perceived, considered and valued, but that is not a characteristic of medical education. In our patients and clinical studies we have a propensity to measure and value what is measurable. Blood pressure, heart rate, respiratory rate are quantative values which we can define and share. However, other elements of assessment which are arguably highly valued by clinicians such as agitation, sweating, distractability, attentiveness are difficult to measure, but are perceived by clinicians. Ask an experienced clinician to look at a patient in the resus room who has an abmormal respiratory pattern, sweating, agitation then they will comment and value on these findings. However, they will not commonly feature in clinical scores (which favour objective data). This is commonly referred to as Gestalt, but it is not. The signs are there, they are perceived and indeed articulated at handover and between the resus team, but they might not make it onto the nurses observation chart.
Beyond that are more subtle clinical signs such as distractability and other responses that may be difficult to explicitly perceive and share, but which a clinician may sense and use in formulation without perception.
So Gestalt in its purest sense is somewhat contrary to the positivistic pseudo-scientific view that many clinicians hold onto as a model for their practice. Gestalt is one element and pathway that links the acquisition of data through to processing and ultimately to clinical judegement and decision making. In its simplest sense it is an assessment that is greater than its parts, but in the world of emergency medicine the term is often confused with the wider realm of clinical judgement.
- Wikipedia Gestalt Psychology
- Cervellin G1, Borghi L, Lippi G. Do clinicians decide relying primarily on Bayesians principles or on Gestalt perception? Some pearls and pitfalls of Gestalt perception in medicine.Intern Emerg Med. 2014 Aug;9(5):513-9. doi: 10.1007/s11739-014-1049-8. Epub 2014 Mar 8.
- Giovanni Casazza • Giorgio Costantino • Piergiorgio Duca Clinical decision making: an introduction. Intern Emerg Med (2010) 5:547–552
- Gunver S Kienle MD and Helmut Kiene MD Clinical judgement and the medical profession. Journal of Evaluation in Clinical Practice
- Andrea Penaloza, MD; Franck Verschuren, MD, PhD; Guy Meyer, MD; Sybille Quentin-Georget, MD; Caroline Soulie, MD; Frédéric Thys, MD, PhD; Pierre-Marie Roy, MD, PhD Comparison of the Unstructured Clinician Gestalt, the Wells Score, and the Revised Geneva Score to Estimate Pretest Probability for Suspected Pulmonary Embolism Annals of Emergency Medicine. http://dx.doi.org/10.1016/j.annemergmed.2012.11.002
- Julian N. Marewski, PhD; Gerd Gigerenzer, PhD Heuristic decision making in medicine. Dialogues Clin Neurosci. Mar 2012; 14(1): 77–89.
- Body R, Cook G, Burrows G, et al. Can emergency physicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement? Emerg Med J Published Online First: doi:10.1136/ emermed-2014-203832
- Michael J. Dreschera, Frances M. Russelld, Maryanne Pappasb and David A. Pepperc Can emergency medicine practitioners predict disposition of psychiatric patients based on a brief medical evaluation?
- Gerd Gigerenzer and Wolfgang Gaissmaier. Heuristic Decision Making Annual Review of Psychology Vol. 62: 451-482 (Volume publication date January 2011) DOI: 10.1146/annurev-psych-120709-145346
- STEPHEN G. HENRY RECOGNIZING TACIT KNOWLEDGE IN MEDICAL EPISTEMOLOGY Theoretical Medicine and Bioethics (2006) 27:187–213
- Anderson RC, Fagan MJ, Sebastian J. Teaching Students the Art and Science of Physical Diagnosis Am J Med. 2001 Apr 1;110(5):419-23.
- Christopher A. Feddock, MD, MS The Lost Art of Clinical Skills The American Journal of Medicine
Volume 120, Issue 4, Pages 374–378, April 2007
Oh, and if you’re interested in where we are going next, check out this short video based on my talk at the Exeter CEM conference.