Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the Future?
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Clinician Gestalt in Managing Pediatric
Pneumonia: Can We Predict
the Future?
Yasaman Fatemi, MD,a,b Louis M. Bell, MDb,c
It’s tough to make predictions, physicians were asked to estimate the
especially about the future. probability that patients with suspected
Yogi Berra pneumonia (based on initial patient
In this issue of Pediatrics, Gao et al1 encounter and chest radiograph
examine the value of clinical gestalt in findings) will develop a complicated
predicting the progression to severe and/or severe pneumonia.1 The
disease in children presenting to an authors found that clinician gestalt was
urban pediatric emergency department most sensitive (.90%) when the
with suspected community acquired estimate for a complicated pneumonia
pneumonia (CAP). CAP is one of the was low and most specific (.90%)
most common serious infections of when the probability for complications
a
to develop was judged to be high. Divisions of Infectious Diseases and cGeneral Pediatrics,
childhood, accounting for ∼2 million Children’s Hospital of Philadelphia, Philadelphia,
annual ambulatory visits and 124 000 Clinician gestalt was poorly predictive Pennsylvania; and bDepartment of Pediatrics, Perelman
annual hospitalizations in the United in situations of greater uncertainty (the School of Medicine, University of Pennsylvania,
States alone.2–5 Globally, childhood intermediate range of risk on the Philadelphia, Pennsylvania
pneumonia accounts for significant probability spectrum), indicating that Opinions expressed in these commentaries are
morbidity and mortality, particularly in gestalt alone is not enough to predict those of the authors and not necessarily those of the
disease and that, importantly, clinicians American Academy of Pediatrics or its Committees.
low- and middle-income countries.6
Complications of CAP include pleural tended to underestimate CAP severity. DOI: https://doi.org/10.1542/peds.2020-048637
effusions, empyema, sepsis, and others In general, clinician gestalt alone was Accepted for publication Feb 12, 2021
that may require additional procedures, insufficient to reliably discriminate Address correspondence to Louis M. Bell, MD,
ICU stays, and prolonged antibiotic which child was at risk for developing Children’s Hospital of Philadelphia, 3401 Civic Center
courses. The management of CAP relies a complicated pneumonia, with an area Blvd, Philadelphia, PA 19104. E-mail: belll@chop.edu
on appropriate diagnosis as well as under the curve of 0.747. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
thoughtful risk stratification to inform 1098-4275).
The definition of clinical gestalt has
decisions, such as antimicrobial choice, Copyright © 2021 by the American Academy of
some variability and at times is used Pediatrics
patient disposition, and follow-up
timing. Clinicians are often required to interchangeably with the term “gut FINANCIAL DISCLOSURE: The authors have indicated
make these types of diagnoses and feeling” or intuition. Here we will refer they have no financial relationships relevant to this
initial management decisions on the to the general concept of clinical gestalt article to disclose.
basis of brief encounters with patients. as a physician’s implicit assessment as FUNDING: No external funding.
The impressions made on these visits applied to diagnosis, the need for POTENTIAL CONFLICT OF INTEREST: The authors have
often rely on a heuristic (ie, shortcut) further evaluation, and prognosis. indicated they have no potential conflicts of interest
approach to diagnosis and Indeed, published studies of clinicians’ to disclose.
management. Much of medical ability to predict the future seem to fall COMPANION PAPER: A companion to this article can
into 3 categories: (1) predicting the be found online at www.pediatrics.org/cgi/doi/10.
decision-making relies on pattern
presence or absence of disease, such as 1542/peds.2020-041582.
recognition, which can include gestalt,
gut feeling, or intuition.7 sepsis or serious bacterial infection8–12;
(2) anticipating the need for further To cite: Fatemi Y and Bell LM. Clinician Gestalt in
Managing Pediatric Pneumonia: Can We Predict
In this prospective cohort study, diagnostic workup to rule out a disease
the Future?. Pediatrics. 2021;147(5):e2020048637
pediatric emergency medicine or injury, such as appendicitis,
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PEDIATRICS Volume 147, number 5, May 2021:e2020048637 COMMENTARYpulmonary embolism, or extremity provider’s knowledge and experience day of antibiotic initiation for
fracture7,13,14; and (3) estimating and results in an immediate concern potential sepsis.9 Other studies in
the risk of disease progression requiring immediate action or which a scoring system based on
(as exemplified in the study reassurance.17 In a pediatric primary aspects of clinical assessment is used
by Gao et al1). care setting, a gut feeling of concern to predict the presence of invasive
based on both the clinician and bacterial infection in febrile infants
Dual process theory, the process of
parent’s concern for serious illness have revealed poor
implicit or explicit thought
has been demonstrated to be performance.11,12,22
generation, has been applied to
associated with subsequent
clinical diagnostic reasoning, and 2
development of severe infection.10 The performance and value of
systems of thinking have been clinician gestalt in management
Another study revealed that a general
proposed: analytic (or “slow decisions will likely be affected by
practitioner’s sense of alarm for
thinking”) and nonanalytic (or “fast external factors, such as the
patients with dyspnea was associated
thinking”). These 2 systems of environment and time pressures of
with a twofold increase in posttest
thinking together result in a busy urban emergency department
likelihood of a life-threatening
a clinician’s assessment of a patient’s
disease.18 setting as compared with an
diagnosis.15 Nonanalytic thinking is ambulatory care setting. One of the
typically thought of as incorporating The concept of clinical gestalt goes limitations of the Gao et al1 study, as
pattern recognition, thereby creating beyond the binary positive the authors point out, was the low
a gestalt of the patient’s condition. (heightened concern) or negative number of patients who developed
The clinician’s gestalt of a patient’s (reassured) determination of severe complications, potentially
condition is typically enhanced by a patient’s current state or trajectory making it difficult to find an
experience and a knowledge base. of illness. Instead, clinical gestalt is association. In the future, it would be
Gao et al1 found that experienced a more generalized physician interesting to explore how clinician
clinicians were better able to predict intuition of a patient’s condition, gestalt is impacted by immediate
the development of a complicated or based on signs and symptoms, contextual factors (including practice
severe pneumonia than their less- knowledge of epidemiology, and setting and type, work environment,
experienced colleagues, with an area estimated pretest probability that is and tools and technologies used),
under the curve of 0.747 vs 0.693, used to predict the diagnosis, the patient factors (such as language
respectively. In another study, need for escalation of care, and the proficiency and parental concern),
clinician gestalt used to estimate the overall trajectory of disease. Gestalt and societal factors, such as racial
pretest probability of pulmonary seems to be most accurate in bias. Increasingly, there is recognition
embolism improved with experience.7 predicting a patient’s diagnosis or that racial bias affects other
To overcome the experience prognosis at the extremes of subjective clinical assessments, such
advantage, clinical prediction rules probability, particularly in negative as pain severity.23,24 It would be
were developed to approximate predictive value, as seen in predicting important to examine the effect of
clinician gestalt; the Pulmonary likelihood of fracture in minor these biases on gestalt accuracy as
Embolism Rule-out Criteria trauma,14 pulmonary embolism,7,19 well.
(commonly referred to as PERC), is and pediatric appendicitis.13 This
a quantified measure of experienced pattern is also reflected in the The authors should be commended
clinical assessment.16 findings by Gao et al.1 for their study of gestalt and clinical
Beyond clinician gestalt, it has been Although clinical gestalt has value, it reasoning. They remind us to be
suggested that intuition or gut is important to keep in mind that it is cognizant of how we arrive at
feelings exist at the extremes of also prone to error and biases and is a working diagnosis and predict the
nonanalytic medical decision-making. not sufficient to guide medical course of illness. Additionally, by
Gut feeling is a mode of cognition decision-making and should be demonstrating the limitations of
that involves rapid unconscious combined with evidence-based gestalt, they highlight the potential to
processing and has been proposed as decision-making tools when augment gestalt (and lack of
being slightly different from gestalt.17 possible.20,21 One study of physician experience) with evidence-based
Clinician intuition, or gut feeling, has ability to predict positive blood decision rules. Thus, to predict the
been studied in primary care settings. culture results revealed poor ability future, there is value in systematically
The gut feeling is immediate and to predict bacterial sepsis even 1 day coordinating nonanalytic (gestalt,
combines previous knowledge gained before; however, clinicians were able intuition, gut feeling) and analytic
by the relationship with the patient or to reasonably discriminate sepsis by (evidence-based) reasoning to
family with the primary care positive blood culture result on the improve medical decision-making.
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2 FATEMI and BELL8. Fischer JE. Physicians’ ability to 17. Stolper E, Van de Wiel M, Van Royen P,
ABBREVIATION diagnose sepsis in newborns and Van Bokhoven M, Van der Weijden T,
CAP: community acquired critically ill children. Pediatr Crit Care Dinant GJ. Gut feelings as a third track
pneumonia Med. 2005;6(suppl 3):S120–S125 in general practitioners’ diagnostic
reasoning. J Gen Intern Med. 2011;
9. Fischer JE, Harbarth S, Agthe AG, et al.
26(2):197–203
Quantifying uncertainty: physicians’
estimates of infection in critically ill 18. Barais M, Fossard E, Dany A, Montier T,
REFERENCES neonates and children. Clin Infect Dis. Stolper E, Van Royen P. Accuracy of the
2004;38(10):1383–1390 general practitioner’s sense of alarm
1. Gao HM, Ambrosio L, Shah SS, Ruddy when confronted with dyspnoea and/or
RM, Florin TA. Predictive value of 10. Van den Bruel A, Thompson M, Buntinx
F, Mant D. Clinicians’ gut feeling about chest pain: a prospective observational
clinician “gestalt” in pediatric study. BMJ Open. 2020;10(2):e034348
community-acquired pneumonia. serious infections in children:
Pediatrics. 2021;147(5):e2020041582 observational study. BMJ. 2012;345: 19. Hendriksen JMT, Lucassen WAM, Erkens
e6144 PMG, et al. Ruling out pulmonary
2. Katz SE, Williams DJ. Pediatric embolism in primary care: comparison
community-acquired pneumonia in the 11. Nigrovic LE, Mahajan PV, Blumberg SM,
et al.; Febrile Infant Working Group of of the diagnostic performance of
United States: changing epidemiology, “gestalt” and the wells rule. Ann Fam
diagnostic and therapeutic challenges, the Pediatric Emergency Care Applied
Research Network (PECARN). The Yale Med. 2016;14(3):227–234
and areas for future research. Infect
Dis Clin North Am. 2018;32(1):47–63 Observation Scale score and the risk of 20. Berner ES, Graber ML. Overconfidence
serious bacterial infections in febrile as a cause of diagnostic error in
3. Kronman MP, Hersh AL, Feng R, Huang infants. Pediatrics. 2017;140(1): medicine. Am J Med. 2008;121(suppl 5):
YS, Lee GE, Shah SS. Ambulatory visit e20170695 S2–S23
rates and antibiotic prescribing for
children with pneumonia, 1994-2007. 12. McCarthy PL. Observational assessment 21. Cook C. Is clinical gestalt good enough?
Pediatrics. 2011;127(3):411–418 in the febrile infant. Pediatrics. 2017; J Manual Manip Ther. 2009;17(1):6–7
140(1):e20171100
4. Lee GE, Lorch SA, Sheffler-Collins S, 22. Baker MD, Avner JR, Bell LM. Failure of
Kronman MP, Shah SS. National 13. Simon LE, Kene MV, Warton EM, et al. infant observation scales in detecting
hospitalization trends for pediatric Diagnostic performance of emergency serious illness in febrile, 4- to 8-week-
pneumonia and associated physician gestalt for predicting acute old infants. Pediatrics. 1990;85(6):
complications. Pediatrics. 2010;126(2): appendicitis in patients age 5 to 20 1040–1043
204–213 years. Acad Emerg Med. 2020;27(9):
821–831 23. Meghani SH, Byun E, Gallagher RM. Time
5. Jain S, Williams DJ, Arnold SR, et al.; to take stock: a meta-analysis and
CDC EPIC Study Team. Community- 14. Mouw M, Balatiouk-Lance T, Brown LH. systematic review of analgesic
acquired pneumonia requiring Can physician and patient gestalt lead treatment disparities for pain in the
hospitalization among U.S. children. N to a shared decision to reduce United States. Pain Med. 2012;13(2):
Engl J Med. 2015;372(9):835–845 unnecessary radiography in extremity 150–174
trauma? Am J Emerg Med. 2015;33(11):
6. Walker CLF, Rudan I, Liu L, et al. Global 24. Sabin JA, Greenwald AG. The influence
1692–1699
burden of childhood pneumonia and of implicit bias on treatment
diarrhoea. Lancet. 2013;381(9875): 15. Croskerry P. A universal model of
recommendations for 4 common
1405–1416 diagnostic reasoning. Acad Med. 2009;
pediatric conditions: pain, urinary
84(8):1022–1028
7. Kabrhel C, Camargo CA Jr., Goldhaber tract infection, attention deficit
SZ. Clinical gestalt and the diagnosis of 16. Patel JJ, Bergl PA. Illuminating gestalt in hyperactivity disorder, and asthma.
pulmonary embolism: does experience diagnosing acute pulmonary embolism. Am J Public Health. 2012;102(5):
matter? Chest. 2005;127(5):1627–1630 Am J Med. 2020;133(2):e62–e63 988–995
Downloaded from www.aappublications.org/news by guest on May 11, 2021
PEDIATRICS Volume 147, number 5, May 2021 3Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the
Future?
Yasaman Fatemi and Louis M. Bell
Pediatrics originally published online April 26, 2021;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2021/04/22/peds.2
020-048637
References This article cites 24 articles, 9 of which you can access for free at:
http://pediatrics.aappublications.org/content/early/2021/04/22/peds.2
020-048637#BIBL
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Downloaded from www.aappublications.org/news by guest on May 11, 2021Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the
Future?
Yasaman Fatemi and Louis M. Bell
Pediatrics originally published online April 26, 2021;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2021/04/22/peds.2020-048637
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2021
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
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