“When you reach the end of what you should know, you will be at the beginning of what you should sense.” ― Kahlil Gibran, Sand and Foam
Some years back a colleague asked for my opinion on a patient he was getting ready to anesthetize for coronary artery bypass grafts. Something about the patient bothered him. About a week earlier, said patient developed chest pain while helping his daughter move. A visit to the ER led to diagnosis of Acute Coronary Syndrome and soon he was on the table in the cardiac catheterization lab where he was found to have three-vessel disease and was scheduled for surgery.
Preoperatively, even though he was not having any chest pain, no shortness of breath or EKG changes, something about his affect bothered my colleague. I took a look at the patient and concurred that his affect was weird. There was just something we couldn’t put our fingers on.
The patient was wheeled back into the operating room and before induction, my colleague decided to place defibrillator pads on the patient. There was no rhyme or reason for him to do that but he did it anyway.
Well guess what happened on induction? The patient went into ventricular fibrillation! With the pads in place, he was able to be shocked out of it and resuscitated. He went on to have his surgery and did well, allowing my colleague to look like the hero that he was.
That nagging feeling! Anyone who has been in patient care long enough has had it. Nurses and doctors alike. It is called intuition. A hunch. The definition I favor is “a thing that one knows or considers likely from instinctive feeling rather than conscious reasoning.”
As in the above scenario, instinctive feeling rather than conscious reasoning informed the decision to place defribillator pads. I could give several more actual scenarios.
Even though almost every physician has these episodes, the majority do not talk about them. How could we? Beside sounding like one wears tin-foil hats, insurance companies do not pay for decisions based on intuitions and most hospital boards do not take kindly to care based on hunches. So we keep these hunches to ourselves and may occasionally base a clinical decision on it. It does not mean that one always makes decision based on hunches. NO! These are rare occasions where something tugs at one over a case that cannot be explained by the evidence.
In most situations, clinicians do not pay attention to their intuitions. The inclination to act on a hunch increases as the outcome of a case or the prognosis for a patient worsens. So in cases where death is imminent, clinicians have been known to act on intuition as acts of last resort, sometimes saving the day.
A group of physicians who use intuition quite often are older colleagues and family practitioners. I remember my days practicing with an older family practitioner (Dr. M) in Berlin. We had a diabetic patient whose blood sugar levels were uncontrollable. She seemed to take her meds and swore she followed her diet. We wanted to have her admitted but she wouldn’t hear of it.
One afternoon after lunch, Dr M asked me to take a walk with him. We soon found ourselves before the door of an apartment about 2 miles away. From outside, one caught the smell of freshly baked cake. DR M rang the bell. The diabetic patient opened the door and the smell of cake hit us in the face. The minute she saw us, she got this silly look on her face. We had our diagnosis from the hunch of an older colleague.
So where do these hunches come from? I seems to be a function of age and experience. Dreyfus and Dreyfus in “Mind over machine: The power of human intuition and expertise in the era of the computer. Oxford: Blackwell 1986” write:
“The novice practitioner is characterized by rigid adherence to taught rules or plans, little situational perception; and no discretionary judgement.
The competent practitioner is able to cope with ‘crowdedness’ and pressure, sees actions partly in terms of long-term goals or wider conceptual framework; and follows standardized and routinized procedures.
The expert practitioner no longer relies explicitly on rules, guidelines, and maxims, has an intuitive grasp of situations based on deep, tacit understanding; and uses analytic approaches only in novel situations or when problems occur.” (T. Greenhalgh, British Journal of General Practice, May 2002).
There is also the factor of empathy – being able to understand one’s patients and sense their needs. That is also often a function of time and experience
So what is one to do? I think one should not disregard these hunches. How one handles these hunches will definitely spend on specialty. As anesthesiologists, I’ll recommend finding a colleague who believes in intuition and running your thoughts by him or her. Often, they are able to offer another perspective. If the intuition demands a procedure that is not too invasive or expensive or will not delay or prolong care, one may consider doing it. It is surely another story if it could lead to say, a case for surgery getting cancelled.
It is surely possible to weave evidence-based medicine and clinical intuition to give the best care. If the majority of us aren’t to doing it, maybe we should.