PURPOSEThe clinical literature advises physicians not to trust their intuition. Studies of clinical intuition, however, equate it to early impressions, the fi rst thing that comes to the physician's mind. This study aimed to investigate the validity of this perspective by examining real cases of intuition in family medicine.METHOD Eighteen family physicians were interviewed about patient cases in which they believed that they had experienced an intuition. Cases were included if (1) participants were unaware of the basis of their judgment, or (2) participants talked about the basis of their judgment but believed that it was irrational or unsubstantiated. During the interview, case descriptions were systematically probed following the Critical Decision Method. Transcripts were coded for judgments, informational cues, expectancies, goals, and actions and were reordered into chronological accounts of the decision process. The 2 authors independently categorized cases into 3 emerging decision process types.RESULTS Participants reported 31 cases, 24 of which met inclusion criteria. Three types of decision process emerged: gut feelings, recognitions, and insights (κ = 0.78). In all cases, participants thought that their intuitive judgment was in confl ict with a more rational explanation or what other colleagues would do.CONCLUSION Automatic, nonanalytical processes in clinical judgment extend beyond fi rst impressions. Rather than admonishing clinicians not to trust their intuition, it should be acknowledged that little is currently known about the different types of intuitive processes and what determines their success or failure. Research on the conditions for accurate clinical intuitions is needed. Ann Fam Med 2013;11:60-66. doi:10.1370/afm.1433. INTRODUCTIONT here is a recognized tension between clinical intuition being seen as the mark of an expert and as mere guesswork, unnecessary in the age of evidence-based medicine.1 Both perspectives agree that intuition eludes understanding, which contributes to the interest it generates.2,3 Intuition, ie, making judgments without any awareness of reasoning, however, has been the subject of robust scientifi c inquiry in psychology for at least 40 years. Intuitive decision making has been found in some cases to improve decisions 4-6 and lead consistently to better performance than analytic deliberation. [7][8][9] The clinical literature nevertheless warns doctors against intuition to avoid reasoning errors and cognitive biases. [10][11][12][13] Much of this literature is opinion-based and attempts to apply psychological concepts to medical diagnosis without empirical testing.A small number of empirical studies have attempted to compare diagnostic accuracy under conditions of analytical vs nonanalytical processing with mixed results. For example, residents in internal medicine who were instructed to apply an analytical approach diagnosed complex cases more accurately than those relying on fi rst impressions.14 Studies of visual diagnosis using student participants p...

Eliciting user decision requirements for designing computerized diagnostic support for family physicians 3 3 Authors biographies Talya Porat is a researcher in human-computer interaction, human factors and cognitive engineering, with a special interest in the medical field. She led the work on interface design for the diagnostic support tool. Olga Kostopoulou is a psychologist studying judgment and decision making, with a focus on diagnostic reasoning, error and cognitive biases. She led the overall project for the development and evaluation of the computerized diagnostic support tool. Amanda Woolley obtained her PhD in Psychology under the supervision of Olga Kostopoulou. She studied clinical intuition in family medicine from a cognitive psychology perspective.

The Unconscious Thought Theory argues that making complex decisions after a period of distraction can lead to better decision quality than deciding either immediately or after conscious deliberation. Two studies have tested this Unconscious Thought Effect (UTE) in clinical diagnosis with conflicting results. The studies used different methodologies and had methodological weaknesses. We attempted to replicate the UTE in medical diagnosis by providing favorable conditions for the effect, while maintaining ecological validity.Family physicians (N=116) diagnosed three complex cases in one of three thinking modes: immediate, unconscious (UT) and conscious (CT). Cases were divided into short sentences, which were presented briefly and sequentially on computer. After each case presentation, the immediate response group gave a diagnosis; the UT group performed a 2-back distraction task for 3 minutes before giving a diagnosis; and the CT group could take as long as necessary before giving a diagnosis.We found no differences in diagnostic accuracy between groups (P=0.95). The CT group took a median of 7 seconds to diagnose, which suggests that physicians were able to diagnose "online", as information was being presented. The lack of a difference between the immediate and UT groups suggests that the distraction had no additional effect on performance.To assess the decisiveness of the evidence of this null result, we computed a Bayes

High tunnel production of horticultural food crops is becoming increasingly popular and has a significant impact on their growth, productivity and nutritional quality. The present study examines the effect of high tunnel production of lettuce (Lactuca sativa cv. "Two Star" and "New Red Fire") and tomato (Solanum lycopersicum cv. "Celebrity" and "Mountain Fresh") on their nutritional quality relating to major nutrients and health-promoting phytochemicals. High tunnel environment increased the concentration of N (protein) in both lettuce and tomato relative to the open field cultivation. The accumulation pattern of mineral nutrients in high tunnel was similar in green-leaf and red-leaf lettuce varieties. Lettuce varieties grown in high tunnel had higher accumulation of C, S and Zn relative to those grown in open field. However, high tunnel environment suppressed the accumulation of many micronutrients such as Mg, Fe, Cu and Mn in both lettuce varieties but not in tomato. For example, accumulation of Fe was reduced by more than 80% in "Two Star" and by more than 55% in "New Red Fire" under high tunnel. It also suppressed the levels of many health-promoting phenolic compounds such as chlorogenic acid, chicoric acid, rutin and kaempferol in green-leaf lettuce and gallic acid in red-leaf lettuce. High tunnel environment improved the soil nutrient status but reduced the radiation levels (PAR, UV-A and UV-B) received by the crops. The results show that the high tunnel production has a significant impact on the nutritional quality relating to protein and mineral nutrients in both crops and health-promoting phytochemicals in lettuce.

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