The intuitive clinician

The dictionary defines intuition as “the ability to understand something without the need for conscious reasoning”. In this essay, I am writing about the ability of the clinician to understand something instinctively. I am narrating events of clinical encounters that I have been involved in, either directly or as an observer. From these events, I intend to draw out the concept of intuition in clinical medicine and to propose its implications for medical practice.

Today was a particularly busy day in our clinic. My colleague, whom I will refer to as SD, and I started the clinic early in the morning and had very little respite through the day till about 3 PM when we could catch our breaths for a break. The hot weather and high humidity compounded the discomfort in the cramped space of the overcrowded clinic. When SD came with a case sheet to discuss a patient, I was half listening to her and half writing my own case sheet of the patient I was attending to. She said that there was this 60-year-old lady with knee pains for whom she wanted to do an electrocardiogram (ECG). “Why would you do an ECG on a lady with knee pain?”, I thought but did not voice out the opinion. SD went on to narrate that this lady had some vague breathlessness and dizziness and she thought something was not ok with the heart. Thinking to myself, “the ECG is anyways going to be normal” I went on with my work. Ten minutes later, SD walks in with the ECG long rhythm strip trailing behind her. One look at the ECG, I could see a very slow heart rate with long pauses in the ECG indicating something seriously wrong with the electrical activity of the patient’s heart, referred to as the Sick Sinus Syndrome. SD started the patient on emergency treatment and referred her immediately to a tertiary care center, for a possible pacemaker treatment. On our way back to the city from the clinic, we were discussing this patient. Why did SD suspect a heart problem in an otherwise normal person? Why did she think of doing an ECG? At the point of ordering the ECG, SD had no clinical clues to a Sick Sinus Syndrome, not even a documented slow heart rate on clinical examination. The only answer SD could give was, “I don’t know sir, I had a feeling that she had a heart problem”.

I would like to narrate another experience I had a couple of years ago. A young 26-year-old gentleman had come to the clinic accompanying his mother. After completing the check up for the mother, I had written her prescription and even as they were getting ready to go, I stopped the young man and asked him if he would like to have his blood pressure (BP) checked. The man said that he did not mind, but he did not have any problems and had never been told that he had high BP in the past. I checked his BP, lo and behold, it was 180 / 100 mmHg, a very high reading. I had no reason to believe that this gentleman would have high BP. But an inner instinct made me check his BP and it was high. I had no rational explanation for this experience.

Everybody who is in the practice of clinical medicine will be able to relate to the two incidents narrated above. It is not uncommon to instinctively feel something is wrong with a patient. We all have moments when we have a “gut feeling” about a diagnosis. What is this instinctive feeling? What is the mechanism of intuitive medicine? Is it important for the practice of medicine? What is its role in today’s technological world of clinical practice?

I think there are two important mechanisms for intuition in medicine. The first is the mechanism of pattern recognition. Fortunately for us, there are some common patterns in which illnesses present themselves. I still remember my professor of pediatrics showing us pictures of children with Down’s syndrome, children with thalassemia, and narrate how they all look very similar. They all have some unique and similar facial features which make them all look very much like one another. Therefore, when one sees a child with either of these disorders, it is not difficult to make a diagnosis instantly. The astute clinician also knows that there are typical smells associated with lung abscess, liver failure, cancerous growths, gangrene of the feet, etc. and it is not difficult to spot the diagnosis even from a distance when patients with these illnesses are there in the ward. This pattern recognition is a very important component of instinctive diagnosis. There is probably a tell-tale look on the face, an abnormal muscle action on the body, unique posturing of the back, a typical smell, which instinctively makes the clinician suspect the diagnosis. Many times, this pattern recognition happens subconsciously and therefore the clinician is not even aware that they have responded to a pattern.

The second mechanism of intuition in medicine is a rapid, multi-level, subconscious reasoning process. In this process of reasoning it is not merely a process of recognition of clinical patterns, but a complex psycho-socio-emotional perception. I would like to narrate one experience to illustrate this mechanism of intuition. I saw a 40-year-old woman in the clinic a few years ago. She came to see me for her blood pressure control. She was on 4 anti-hypertensive medications and still, her BP was poorly controlled. When I examined, it was 160 / 100 mmHg. One thing that was striking about this lady was that she looked very tired, her hair was unkempt, and there were dark circles around her eyes. She looked depressed and withdrawn. I had an instinctive feeling that there was some other non-biomedical reason for her high blood pressure and this instinctive feeling was fuelled by her affect. I asked her about her sleep. It was a very important moment in our encounter. From that point, the entire course of her treatment changed. When I asked her about her sleep, it was like the flood gates opened and she started crying. She had not slept soundly for the past 30 years and was always tired, sleepy and disinterested in day to day work. She told me that after the delivery of her second child, she went through “psychological problems” and was treated with some medicines. The medicines never helped her and after that, she could never sleep well. She had seen a few doctors in the early stages of her sleep problems, but she never received adequate treatment. About 10 years ago, she developed the high BP, but by then her lack of sleep had become routine and nobody had ever been able to help her that she stopped mentioning the sleep trouble to anyone. After hearing this story, I started her on treatment for sleep. She started sleeping better. Over the next 3 months, she was off all her anti-hypertensive medicines and was sleeping better and was more cheerful and forthcoming in the clinical visits. In this case, it was not the recognition of a clinical pattern, but a complex psycho-social and an emotional pattern which helped the patient.

I remember I was on duty in the casualty department of the hospital where I was doing my post-graduate training. There was a young woman who was just getting out of her autorickshaw to enter the casualty at around 9 PM at night. Even as she entered the casualty, I was standing there ready with the nebulizer, the asthma medication already loaded in it and ready for administration. One look at her even as she got down from her auto, from the way she was panting, the way her face was contorted in fear and discomfort, the way one could hear the wheezing sound from far away, it was clear that it was an acute exacerbation of asthma. Other points which strengthened the diagnosis were, the auto-rickshaw driver seemed to know very well of her condition, probably a regular companion for her casualty visits. It was too late in the night for a woman to come all alone to the hospital, and she must be a regular to the casualty that she felt comfortable to come at that time. She also seemed familiar with the hospital and casualty. All these pointed to a woman who was an asthmatic, who had regular exacerbations and visited the casualty often for her nebulizations.  These were all subconsciously processed, and I understood all these points only after consciously reflecting on it later.

Therefore, intuitive decision making and intuitive practice of medicine is a skill that develops from paying a lot of close attention to the patient’s narrative, their body language, and the physical examination. This can happen only when the patient and doctor are close to one another. As the literal and figurative distance between the patient and the doctor increases, the chances of exercising intuitive practice diminish. If one does not have the opportunity to watch the patient as they walk into the clinic, the opportunity to ask them about their life, the chance to touch, feel and examine them, the chances of developing intuitive and instinctive decision making reduces substantially. The diminishing value placed on history taking and physical examination have led to a reduction in clinical excitement that is born out of intuitions turning out to be correct and helping the patient. It has also led to increasing health care costs due to over-reliance on diagnostic tests and imaging.

One may ask, how can we leave medicine to be practiced based on subjective experiences of intuition and instinct. This is a real and important concern. One cannot practice medicine based on instincts and gut feelings alone. That would be a dangerous move. Because intuitions are colored by the perceptions, realities, and experiences of the person who has them. They are known to go grossly wrong. Though clinical intuition may not have independent value as a clinical tool, it has value because of what it represents. Clinical intuition represents close attention to patient details. It represents a powerful and sharp observation, and a genuine interest to find solutions for the patients’ problems. Lastly, it represents a reflective and life long learning mindset of the doctor.

There is a very peculiar saying in Tamil about the importance of the experience of a doctor. It goes “aayiram perai saaga vaithavan aria vaithiyan”. Literally translated it means “the one who has allowed a 1000 patients to die is half a physician”. This does not mean killing 2000 makes one a full physician or that being a physician is about killing a lot of people. I interpret this saying to mean that even that physician who has seen a 1000 people live a full life and die a natural death has become only half qualified. I think it emphasizes the need to be close to patients, observe them, sit by them, talk to them, understand them and be part of their full lives, in order to become skilled, intuitive and instinctive clinicians.