On a busy day shift in the emergency department, our seasoned triage nurse comes to me after I finish caring for a hallway patient, “Hey, can you come see this guy in the triage room? His vitals are fine…”. Seemingly unsure, she pauses, “I’m getting an interpreter, and I think he has belly pain, but something just doesn’t seem right.”

Coming into triage, I see a young man—Georgian-speaking—bracing himself with a hand against the wall and holding his lower abdomen. With what I can only describe as a “grimace” by a singular word, his face conveyed so much more. Without talking or touching the patient, the triage nurse picked up on a deep pain. She had subconsciously analyzed the orchestration of 43 facial muscles and the patient’s body language to create an impression, “This patient cannot wait hours in the waiting room to be seen.” Our nurse did not study Paul Ekman’s Facial Action Coding System for Action Units to code “fear” in the patient’s face.¹ Instead, she had a “gut feeling”—a feeling that appears quickly in consciousness, with unclear awareness of the underlying reasons, but is strong enough to act on.²

Coming by different names as “gut feeling,” “gestalt,” or “intuition,” medicine recognizes this skill in clinical decision-making and interpretation. However, it is often juxtaposed against objective evidence—like lab work and imaging—and deemed inferior. Understandably, it is hard to ask a consultant for admission/observation for a patient with unremarkable work-up and vitals just because “I have a hunch.” It’s inherently hard to define and difficult to explain to others. However, gestalt is something emergency physicians use every day and often in conjunction with our objective reasoning. Thus, gestalt should be recognized as a powerful skill to be honed, respected, and coupled often with our objective diagnostics to make timely decisions.

When is Gestalt Helpful?

Gestalt is useful in areas of time-sensitivity and uncertainty. Sound familiar? This is the essence of emergency medicine. Caring for critically ill patients with limited information requires snap assessments and judgements for timely resuscitation and efficient emergency department throughput.

In the age of big data, more information sounds like a boon. However, more data can be extra noise, which is both time-consuming and can be misleading. For example, experienced emergency physicians have great clinical gestalt and accuracy to predict sepsis in critically ill patients at just 15 minutes from patient arrival—more so than scoring tools like the qSOFA, MEWs, and even machine-learning trained artificial intelligence models.³ This clinical judgment is fast—prior to any lab work to help guide a clinician’s suspicions. In such cases, would you wait for a lactate, white blood cell count, bandemia, or other diagnostics to confirm a source of infection before starting antibiotics, fluid resuscitation, and/or pressors? In this study, clinical gestalt is not only fast, but accurate for the benefit of timely resuscitation and intervention.