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• The tension between "gestalt" and the checklist
  oscar,m jolobe
  Published on: 25 April 2019

• Published on: 25 April 2019

  The tension between "gestalt" and the checklist

  • oscar,m jolobe, retired geriatrician manchester medical society

  The tension between head, heart and checklist is strikingly exemplified by the clinical decision process involved in the diagnosis of pulmonary embolism(PE). Currently, this process is characterised by a proliferation of clinical decision rules which involve mind numbingly long lists of items, and their associated calculations, the latter intended to generate numerical scores(1)(2) which confer a semblance of scientific credibility to the process. By contrast, a school of thought has emerged which posits that clinical acumen, defined as unstructured clinical impression or "gestalt" is, at the very least, as reliable a sole reliance on clinical prediction rules for discriminating among patients who have a low, moderate, or high pretest probability of PE(1). Over time, gestalt, itself, appears progressively to confer increasing diagnostic accuracy, judging by the diagnostic performance of senior physicians(postgraduate year 4 plus) vs interns(postgraduate year 1) working in the emergency department of a large teaching hospital(3). Concurrently, we have seen the emergence of gestalt-based clinical decision strategies such as the PERC rule(4) and the YEARS algorithm(5). as an attempt to resolve the tension between underdiagnosis and overdiagnosis of PE.
  Clinical acumen, itself, performs best when it is informed, not only by the numerical score of years since obtaining one's medical qualification, but also by interaction(through the medium of case co...

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  The tension between head, heart and checklist is strikingly exemplified by the clinical decision process involved in the diagnosis of pulmonary embolism(PE). Currently, this process is characterised by a proliferation of clinical decision rules which involve mind numbingly long lists of items, and their associated calculations, the latter intended to generate numerical scores(1)(2) which confer a semblance of scientific credibility to the process. By contrast, a school of thought has emerged which posits that clinical acumen, defined as unstructured clinical impression or "gestalt" is, at the very least, as reliable a sole reliance on clinical prediction rules for discriminating among patients who have a low, moderate, or high pretest probability of PE(1). Over time, gestalt, itself, appears progressively to confer increasing diagnostic accuracy, judging by the diagnostic performance of senior physicians(postgraduate year 4 plus) vs interns(postgraduate year 1) working in the emergency department of a large teaching hospital(3). Concurrently, we have seen the emergence of gestalt-based clinical decision strategies such as the PERC rule(4) and the YEARS algorithm(5). as an attempt to resolve the tension between underdiagnosis and overdiagnosis of PE.
  Clinical acumen, itself, performs best when it is informed, not only by the numerical score of years since obtaining one's medical qualification, but also by interaction(through the medium of case conferences, "grand" rounds, and clinico-pathological discussions) with colleagues who have addressed similar diagnostic challenges in the workplace. Clinical acumen is also enhanced by mining the immensely rich treasure trove of the published literature of typical as well as atypical cases of PE. In that fullest sense unstructured clinical acumen is likely to outrank even the mot ingeniously devised clinical decision rule in its diagnostic performance.
  References
  (1) Chunilal SD., Eikelboom JW., Attia J et al
  Does this patient have pulmonary embolism?
  JAMA2003;290;2849-2858. Also see conclusion by Ginsberg that clinical gestalt strategies and clinical prediction rules have similar discriminate pretest probabilities of pulmonary embolism in www.evidence-basedmedicine.com)
  (2)Wahsh RA., Agha MA
  Clinical probability of pulmonary embolism: Comparison of different scoring systems
  Egyptian Journal of Chest Diseases and Tuberculosis 2012;61:419-424
  (3) Kabrhel C., Camargo CA., Goldhaber SZ
  Clinical gestalt and the diagnosis of pulmonary embolism: does experience matter?
  CHEST 2005;127:1727-1630
  (4)Kline JA., Mitchell AM., Kabrhel C., Richman PB., Courtney DM
  Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism
  J Thromb Haemost 2004;2:1247-1255
  (5)van der Hulle T., Cheung WY., Kaoij S et al
  Simplified diagnostic management of suspected pulmonary embolism(the YEARS study): a prospective, multicentre, cohort study
  Lancet 2017;390:1890197
  Review:clinical gestalt strategies and clinical prediction rules have similar discriminate pretest probabilities of pulmonary embolism

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  Conflict of Interest:
  None declared.

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