Should I draw a venous or arterial blood gas before deciding on intubation? Should I wait for imaging results or labs for this trauma patient before deciding on starting blood or placing a chest tube? Does that normal troponin and ECG obviate the need for cardiology consultation for my patient with a concerning story for acute coronary syndrome? Procrastination to prevent risk—for fear of misdiagnosis or incorrect treatment—can contrarily increase risk for the patient. Furthermore, a contradictory data point can erroneously result in inaction (‘analysis paralysis’) or, worse, steer care in an incorrect direction.

Arguably, emergency medicine has the broadest range of patient presentations among all specialties coupled with a high degree of uncertainty. For example, syncope is a complaint with broad diagnostic uncertainty and up to 40 percent of the time there is no clear diagnosis for syncope.⁴ However, emergency physicians rely on gestalt to predict outcomes well. The externally validated Canadian Syncope Risk Score (CSRS) demonstrated no better prediction of 30-day adverse outcomes for “very low” and “low” risk patients than clinical judgment alone of emergency physicians.

In the diagnosis of pulmonary emboli, experienced emergency physicians’ gestalt performed similarly to prediction rules of PERC, Revised Geneva, and Wells.^5,6 Emergency physicians are not necessarily drawing troponins (only about 50 percent of patients in the syncope comparison study even had a troponin), calculating ECG axis, or asking every patient about hemoptysis as warranted by these decision instruments. Yet, they obtain similar results and arguably with less logistical and time hassle than these decision instruments warrant. Undifferentiated or vague complaints require gestalt to pursue a differential diagnosis and disposition.

Honing Gestalt

1. Recognize gestalt as a critical component to decisions

Gestalt is a skill that everyone uses, but seldom appreciates. Part of this problem stems from the misconception: Gestalt is antithetical to rationality. “Going by feeling” or intuition is often misconstrued as irrational or not dependable. However, gestalt is almost always at play in many decisions and works with reasoning to create rationality. Deliberate reasoning is crucial to make an educated decision, but there are unaccounted factors—our gestalt—that play into overall impression. Although we may reason that the elevated troponin is an NSTEMI, it is our gestalt that helps develop an overall impression that this is a Type I vs. Type II NSTEMI. We should respect this gut feeling as a contributory entity. Afterall, this gut feeling is built from years of perspectives, our unique experiences, and hidden cues.