Gestalt is a valuable component of our thought process and sometimes, an impetus strong enough to lead us to action. The astute triage nurse—based on gestalt—moved to earlier physician evaluation. The young man ended up having a left testicular torsion for the last three hours. After some fentanyl, applying traction, and “opening the book,” he improved. A testicular ultrasound confirmed restored blood flow. Urology took him for orchiopexy.

Respecting gestalt is owning it as a skill that we can improve. However, respect for gestalt is also recognizing its limitations. Quick judgements are prone to inaccurate and harmful bias. Having a recent patient with an aortic dissection may make one pursue excessive “aortic dissection” workups with their subsequent chest pain patients (recency bias). One may overlook counter examples or conflicting evidence in search of confirming evidence for their initial impression (confirmation bias). One may inadequately assess and treat pain in a Black patient with a sickle cell crises (implicit bias).⁹ It’s imperative to create “cognitive pauses” to assess our clinical gestalt and ask ourselves: Is detrimental bias involved?

In addition, gestalt is only as strong as a foundation of clinical knowledge. If you haven’t learned it, you can’t diagnose it or treat it. It’s important to continually learn changing clinical foundations and review evidence-based clinical knowledge. The subconscious has been an important part of medical decision making for millennia and should continue to be integral to our clinical care.

Dr. Koo is faculty and an emergency physician at MedStar Washington Hospital Center in Washington, D.C., and St. Mary’s Hospital in Leonardtown, Maryland.

References

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