Bioethics Discussion Blog: Intuition and the Practice of Medicine

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Sunday, January 10, 2010

Intuition and the Practice of Medicine

"The most decisive actions of our life... are most often unconsidered actions." ~André Gide, The Counterfeiters, 1926


But is what Gide writes intuition? If “unconsidered actions” is really the consequences of intuition, is that what physicians use in making diagnoses and establishing treatment? A dictionary definition of intuition would be the act or faculty of knowing or sensing without the use of rational processes; immediate cognition. Knowledge gained by the use of this faculty; a perceptive insight or a sense of something not evident or deducible; an impression. Other words can also express intuition such as feeling, hunch, idea, impression or suspicion. But, do you think that these words describe what goes on in the mind of a physician when attending to a patient? My answer would be “well..yes, well..no”. First, there is debate as to how to define the word intuition when it is applied to the medical profession. Does it represent a “made-up” theory or assumption without any connection to previously established facts? Or is it a professional way to look at and interpret any facts that are available? Obviously, I can’t tell you what is going throughout the mind of any doctor except myself. To me, however, I find that I use intuition as a method in which I can personally make sense of the facts, both historical including my experience and contemporary. In medicine, simply laying out and evaluating the facts developed in taking a history, performing a physical examination and performing tests or procedures may be clearly insufficient toward coming to a conclusion. The diagnosis or the decision regarding further workup or treatment may still be ambiguous. It takes something more to feel confident to initiate action. That something more, I think, is intuition.


Intuition in medicine has nothing to do with ignoring or setting aside all the facts and proceeding de novo with some innate unexplained but significant mental mechanism which is “all knowing” or spiritual which has powers beyond any rational understanding of mental or physical mechanisms. I do think that intuition is related to the physician’s personal and professional experiences and recollection of the outcomes of those experiences. This recollection is then applied perhaps rightly or wrongly to the contemporary facts and an attempt is made to mold these facts with intuition into a conclusion for action.


Often, physicians must make critical decisions in short time spans during which time other needs for other decisions are appearing. There may not be enough time and the facts may be inadequate to come to a decision based on these facts. Particularly, in such a situation, doctors turn to intuition. This means that the doctor doesn’t simply look at A and B and C and automatically finds a direction toward action D because of established standards of professional practice or because A, B and C have been recognized and D has been rigorously tested in a controlled scientific study and found to be an appropriate action. This is where intuition plays a role. I say to myself "Will what I have learned in the past about this disease or symptom complex, will what I know about the patient, will what has been the standards of practice regarding this condition, and what has been tested and proven valid by scientific studies really apply to this patient and this patient’s condition?" I think it is intuition that then plays a role in getting a decision defined. It may become, as an answer to these questions, “yes, yes, yes, yes” or “yes, yes, yes,yes… but…” and it is the “but” which represents the physician’s use of intuition. My conclusion is that Gides “unconsidered actions” would not represent intuition particularly the way I have used intuition and the way I suspect other doctors have used it in medicine.


As a patient, how to you feel about the physician’s use of intuition, as you define it, and whether you think it is something that doctors should use? Do you have any examples of how your doctor’s intuition played a role in your illness? ..Maurice.

7 Comments:

At Monday, January 11, 2010 3:57:00 PM, Blogger Billy Rubin said...

Hello Doc Bernstein! A provocative post as always (and "provocative" in the best sense of the word, not "titillating").

From my perspective (as a doc), I found my "intuition" to be not helpful as a patient the one time I actually needed medical help. I was coming back from a one-day conference last year and, while sitting in the airport, felt a major ache in my left calf. When it didn't go away, I realized that I must have gotten a DVT (blood clot in the legs for the non-specialist) on the flight the previous eve. Only I was wrong: in the ER that night after I disembarked they found no evidence of clot on the ultrasound. Instead I had MRSA cellulitis. I thought it was instructive for me as a doc in what I would have regarded as a textbook story for DVT. I mean, that's how they teach it in med school! It was a humbling experience and made me realize the limits of "intuition."

On the other hand, two months ago I admitted a guy who had a gift-wrapped diagnosis of pneumonia in a 35 year-old guy that looked classic: leukocytosis (high white count usually indicating infection), fever, racing heart, suboptimal oxygenation, and clear-cut evidence of an "infiltrate" on x-ray, which 9 times out of ten in that situation indicates pneumonia. The PCP was convinced, the ER doc was convinced; all I really needed to do was continue antibiotics. But after talking to the patient about his recent history, my intuition said that it was highly unlikely to be pneumonia, and I got a CT scan which revealed the real diagnosis, which was that he had a blood clot in his lungs. The potentially lifesaving treatment was blood thinners, not antibiotics. There my intuition that something was awry was helpful (and I knew I'd find a clot in somebody if not myself!).

You may be acquainted with Malcolm Gladwell's great book "Blink," in which he explores the phenomenon of intuition, and in particular the intuition of experts. My take-home is that I try to be as skeptical of my own intuition as I am of "objective" test results. Sometimes you're going to have cases where all the information and your intuition are going to point you in one direction...and you still may not be right. It is the nature of the beast; diagnostic medicine is a science, but it ain't an absolutely foolproof one.

As for patients, I think they should always trust their intuition when it comes to how they regard their doctors. If it don't feel comfortable, time to find another doc.

 
At Monday, January 11, 2010 4:26:00 PM, Blogger Maurice Bernstein, M.D. said...

Billy, I think you presented two good examples of how intuition doesn't work and how it does. I suspect the if the intuition deals with a very personal issue of the one making the intuition, there may be psychologic factors which distort intuition and more likely lead to the wrong conclusion. Whereas intuition may be more "objective" as a subjective function and be of more value when the decision is made for the benefit of others. I haven't investigated this conclusion in the literature but it is just what I suspect. ..Maurice.

 
At Tuesday, January 12, 2010 4:15:00 PM, Anonymous medrecgal said...

Well, all I can say is that from a patient perspective, some form of a physician's intuition that led him to perform a surgery that others wouldn't touch because of my age and sickness at the time was nothing short of lifesaving. There are, of course, all sorts of other factors and circumstances playing into things like the decision to operate (or not to, as the case may be), but it is my belief that intuition, which I see as that gut sense that some treatment or surgery just might stand a chance of working even when things look rather bleak, can be a powerful tool in a doctor's arsenal.

 
At Wednesday, March 03, 2010 11:00:00 PM, Blogger matsajoy said...

It is interesting to see a blog that discusses intuition and that too in practice of medicine. I agree with the fact that intuition works in some cases and not in others. the possible explanation is it is 'objective' when applied for others but more biased when used for self. But it has to be noted that intuition is only a personal reflection/manifestation of the analysis of contextual events happening around. Thus it is more dependent on the sociocultural context as well as human psyche, the latter again dependent on the context. Thus I feel intuition is more a patterned, reflection or analysis happening at the sub-conscious level.

My concern has been more towards the uncertainty involved in medical practice where billy's experience says that 9 out of 10 cases indicate pneumonia and so followed that. But isn't it medical practice is based more on probabilities where always there is a chance of the unexpected? In that case intuition which is only one of the tools for practice can also be biased?

 
At Thursday, March 04, 2010 1:17:00 PM, Blogger Maurice Bernstein, M.D. said...

Matsajoy, you write "But isn't it medical practice is based more on probabilities where always there is a chance of the unexpected?"

My response "absolutely!"

Even with the best of evidence-based medical practice, there is always the truism that the sensitivity and specificity of a finding will never both be 100%. That is, that the cluster of symptoms and findings 100% of the time will define a patient who has that disease. And that 100% of the time no patient who doesn't have the disease will have that cluster of symptoms and findings. Well, not unless someone is declared dead..but even that we have all heard of stories of patients found to be alive in the morgue. There is no absolute certainty in medicine, facts or intuition. ..Maurice.

 
At Monday, April 09, 2012 1:13:00 PM, Anonymous Monica said...

This is a very interesting topic to be discussed upon. I have a Philosophy topic relating to this, which is 'Medical Intuition'. I was finding some information in the internet and came across yours, Doctor. It was very helpful. But was just hoping if you could help me more on the topic. Thank you...Monica

 
At Monday, April 09, 2012 3:31:00 PM, Blogger Maurice Bernstein, M.D. said...

Monica, if you have a school assigned topic (such as a philosophical topic)for which a response is not based on rigid empiric criteria that has been clearly documented and can be looked up and presented as such, you need to enter the conversation with your own views and then learn from any subsequent discussion with others. So.. the first thing you should do is tell us what you have already learned about medical intuition and what are your own views of this subject. ..Maurice.

 

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