In­tu­ition still has a role to play in med­i­cal de­ci­sions

The Irish Times - Tuesday - Health - - Health Lifestyle - Muiris Hous­ton mhous­[email protected]­

Would you like to be treated by a doc­tor who re­lies on his gut in­stinct? And have you ever found your­self in­tro­duc­ing a com­pletely new symp­tom or con­cern just as you were leav­ing the con­sul­ta­tion room?

The link be­tween these ap­par­ently ran­dom ques­tions lies at the heart of medicine as an art rather than a sci­ence. While the prin­ci­ples of mod­ern medicine are rooted in sci­ence, its prac­tice can be a more sub­jec­tive ex­er­cise. And not in a bad way, I has­ten to add.

I have used med­i­cal in­tu­ition through­out my pro­fes­sional life. It’s not al­ways cor­rect, of course, al­though on a num­ber of oc­ca­sions it has led to an early di­ag­no­sis of can­cer in a pa­tient. But as a pro­po­nent of nar­ra­tive medicine and re­flec­tive prac­tice, fol­low­ing gut feel­ings is some­thing I’m definitely com­fort­able with.

A new study has high­lighted the im­por­tant role hu­man in­tu­ition plays in med­i­cal de­ci­sions. Sci­en­tists at the Mas­sachusetts In­sti­tute of Tech­nol­ogy (MIT) an­a­lysed 10 years of data on pa­tients in in­ten­sive care and found that doc­tors’ gut feel­ings about how their pa­tients were do­ing in­flu­enced how many tests they or­dered.

The re­searchers col­lected in­for­ma­tion on all fac­tors a doc­tor might con­sider in de­cid­ing to or­der tests, in­clud­ing a pa­tient’s age, dis­ease type and sever­ity.

They also mea­sured doc­tors gut feel­ings about their pa­tients by analysing pa­tient notes us­ing an al­go­rithm that scores text for pos­i­tive and neg­a­tive sen­ti­ment.


When doc­tors were more pes­simistic about a pa­tient’s con­di­tion, they tended to or­der more tests – but only up to a point. If they felt very neg­a­tive about the pa­tient’s prog­no­sis, they or­dered fewer tests. This ef­fect was strong­est at the be­gin­ning of a pa­tient’s hospi­tal stay, when doc­tors had less med­i­cal in­for­ma­tion to go on, and de­clined over time.

The MIT study is es­pe­cially rel­e­vant in ex­plain­ing why there can be so much vari­a­tion in the use of med­i­cal resources. And at a time when tick-box medicine threat­ens to rule health­care, feed­ing into a model beloved of ad­min­is­tra­tors bent at cut­ting costs what­ever the con­se­quences, it’s a suit­able re­minder of why time spent with pa­tients trumps for­mu­laic care ev­ery time.

A pa­per in the Jour­nal of Gen­eral In­ter­nal Medicine con­cludes that the ear­li­est im­pres­sions a doc­tor forms when con­fronted with a prob­lem are of­ten more ac­cu­rate than a later anal­y­sis. A BMJ pa­per found that a doc­tor’s gut feel­ing that some­thing was wrong when treat­ing a child in pri­mary care can have greater di­ag­nos­tic value than many signs and symp­toms. In­ter­est­ingly, in this study, the level of clin­i­cal ex­pe­ri­ence didn’t seem to mat­ter; a doc­tor’s in­tu­ition about a child’s con­di­tion was pri­mar­ily in­flu­enced by how much the par­ents were con­cerned, but when it came to the di­ag­nos­tic value of the gut feel­ing, the clin­i­cian’s level of ex­pe­ri­ence made no dif­fer­ence.


It ap­pears med­i­cal in­tu­ition may have more to do with em­pa­thy than ex­per­tise. Fam­ily doc­tors who scored high­est on em­pa­thy were four times as likely to re­port us­ing gut feel­ings in prac­tice com­pared to those who scored low­est on em­pa­thy.

Fam­ily doc­tors who scored high­est on em­pa­thy were four times as likely to re­port us­ing gut feel­ings in prac­tice

Mean­while so called “door han­dle” con­sul­ta­tions are an­other sub­jec­tive phe­nom­e­non in med­i­cal prac­tice. Typ­i­cally, the is­sue of ap­par­ent pri­mary con­cern to the pa­tient has been dealt with com­pre­hen­sively, when, on the point of ex­it­ing the room, the per­son says “Oh by the way doc­tor...”

In some cases, these late in­ter­ven­tions have been shown to be the real rea­son for the con­sul­ta­tion-only for the per­son, for rea­sons in­clud­ing anx­i­ety or em­bar­rass­ment, to present with an en­tirely dif­fer­ent prob­lem at the out­set.

Doc­tors are trained to swal­low feel­ings of frus­tra­tion about the ef­fect of deal­ing with a new gam­bit will have on their ap­point­ment schedule. But it is the art of medicine – in the form of finely tuned em­pa­thy – that de­ter­mines whether the new symp­tom re­quires an im­me­di­ate pro­lon­ga­tion of the con­sul­ta­tion or an in­vi­ta­tion to make a sep­a­rate ap­point­ment.

That’s not some­thing a ro­bot will ever achieve.

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