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Study: GP ‘gut feeling’ better at identifying cancer than referral guidelines

identify cancer

GP ‘gut feelings’ are more useful than official guidelines in identifying potential serious diagnoses, including cancer, new research suggests.

The study, published in the British Journal of General Practice, reviewed six databases for previous research, from inception until July last year, amid ‘growing evidence for the role of GPs’ gut feelings in cancer diagnosis’.

It concluded that GPs conceptualised gut feeling as an ‘uneasy feeling’ – most commonly triggered by a rapid summing up of multiple verbal and non-verbal cues. A cancer diagnosis was more likely in patients for whom the GP had a gut feeling compared with patients for whom the GP did not experience a gut feeling.

The systematic review and meta-analysis of international research examined 12 articles and four online resources. Results included that gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues.

The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded – they became more predictive of cancer as clinical experience and familiarity with the patient increased.

Additionally, despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings. This was because specialists sometimes questioned their diagnostic value, and led to GPs omitting gut feelings from referral letters or chosing investigations that did not require specialist approval.

It also noted that gut feelings, that are an acknowledged component of clinical decision-making in primary care, are often used interchangeably with ‘intuition’, ‘suspicion’, and ‘instinct’.

Co-lead Dr Brian Nicholson, a GP and clinical researcher at the University of Oxford’s Nuffield Department of Primary Care Health Sciences, said: ‘We found research that suggests that gut feelings are more effective at identifying people with cancer than the symptoms and signs used in guidelines. We wanted to understand what leads to a GP having a gut feeling in case the guidelines could be improved.

‘Our findings emphasise that GPs collect and interpret a large amount of information about their patient in a short period of time. Together these pieces of information can lead to a gut feeling that something is wrong. Only some of this information is included in current guidelines.’

RCGP honorary secretary Dr Jonathan Leach said: ‘GPs consider a huge variety of factors when making a patient diagnosis. As well as more obvious physical symptoms, non-verbal cues can often indicate that something is wrong – not necessarily what the patient has made an appointment to speak about.

‘This “gut feeling” or intuition is something that GPs develop by having close, trusting relationships with patients that are often built over time, and isn’t something that should be ignored.’

Dr Leach added that this is ‘also something that should be considered when looking into the way patients access general practice services in the future’, after the pandemic.

‘Remote consultations can be convenient for patients, and they have been vital in helping to stop the spread of the Covid-19 virus and keeping patients safe during the pandemic. However, they can pose challenges for GPs, not least the lack of non-verbal cues that we often use to help us make a diagnosis,’ he said.

A study involving Danish GPs reached similar conclusions, as Pulse reported in 2014 and in 2018, NHS England announced the launch of 10 ‘one-stop-shop’ cancer diagnostics centres for patients with non-specific symptoms.

Dr Richard Roope, Cancer Research UK’s GP expert, said: ‘The authors have a good history and a sound reputation of paper publications. This paper is well researched and confirms what has been widely felt, that general practice continues to be a mix of science and art. As GPs, we deal with uncertainty on a daily basis, and many patients present with symptoms that do not fit pathways that are sometimes very inflexible.

‘This research shows the value of the “gut instinct “ or “sixth sense”. GPs need to exercise extra caution at present with the majority of patient contacts being by phone or e-mail, to compensate for the absence of non-verbal cues. The development of RDCs, which allow GPs to refer patients who have symptoms and clinical features that do not fit a site specific pathway, should enable referral and quick assessment of such patients, and this may be one such pathway along which those who trigger that “gut reaction” can be referred.’

Dr Owen Carter, cancer clinical lead and Macmillan GP at NHS South West London CCG, said: ‘The pan-London referral guidance does include it in its referral criteria, allowing referral onto a suspected cancer pathway if I have clinician concerns even in absence of the referral criteria.’

He added: ‘I think this article does help to provide evidence to what is a useful clinician trigger. As a clinician, I recognise the importance of how significant the “gut feeling” term is, but how difficult it is to describe or teach. This paper does help address some of those issues.’