We should respect our own and others’ gestalt assessments. This means deviating from protocols (when warranted) for sepsis because your initial impression is the patient would be harmed with that much fluid. This means listening to our teams’ words when they say, “I’m worried” or “something just doesn’t fit”. Respect this assessment as a valid concern on its own. This means withholding second-guessing our emergency medical services colleagues for their snap decisions in the field with little objective diagnostics.

2. Developing rules of thumb

Heuristics are “rules of thumb” or mental shortcuts to make fast decisions. They are derived from gestalt to help translate practice patterns into concrete methods. Examples would be as below:

• The “walking wounded” triage heuristic in mass casualty incidents—patient able to walk to you can be initially triaged as “green” or “minimal”.
• The “worst first” mental model—thinking of the most dangerous etiologies first.
• The “bundling” heuristic—if I send a troponin, then an ECG is needed.
• The “escalation” heuristic—when a patient is decompensating with vital signs or mental status, two intravenous catheters and monitoring is needed.

3. Learning from the gestalt of others

Watching and asking other experienced clinicians reveal nuanced insights and check your gestalt. Learning gestalt from others is both a passive and active process. Passively, I watch another clinician’s cursory examination of a critically ill patient to determine how they deem a patient “toxic-appearing” or their bedside neurological assessment to activate a code stroke. Actively, I ask them on their patients that we both had the opportunity to see: What abscesses would they prefer to pack? What do you think the prognosis is for that patient we achieved ROSC?

4. Reflective practice

Deliberate testing of your gestalt prior to confirmation or knowing an outcome can help hone your gestalt for successive cases. An example would be categorizing a patient’s likelihood of pulmonary embolism (PE) into percentages or likelihoods (i.e. a 25 percent chance of PE or low likelihood) prior to any testing, and then reflecting on your predictions after diagnosis. Patterns may emerge on your gestalt. While PERC rule does not differentiate between estrogen use vs. immobilization, reflective practice may reveal that a recent ORIF of a lower leg appears to be a more severe risk factor than oral contraceptive use for deep venous thrombosis and PE.

5. Seeking new perspective and knowledge

Seeing perspectives and experiences from within and outside medicine are instrumental to honing intuition. Speaking and learning from other disciplines may give insight into previously unknown perspectives or skills. Peritonsillar abscesses that I traditionally drained may be more appropriate for antibiotics and steroids alone given otolaryngology literature or perspectives from the outpatient experience of my ENT colleagues.⁷ Playing video games—with the ability to understand spatial relationships and toggle control—may be beneficial to understanding directionality during fiberoptic intubation.⁸ The range of perspectives, skillsets, and experiences we have create an environment for expanded gestalt thinking.