Clinical Intuition in Family Medicine: More Than First Impressions

We have read the article 'Clinical intuition in family medicine: more than first impressions' with interest and we agree with the conclusion that the idea of first impressions is not sufficient to explain clinical intuition. Still we would like to make some remarks.

Firstly, we doubt whether the literature on clinical intuition confines this concept to first impressions. First impressions can be used as a method to study intuitions but this method does not constitute the concept.(1;2) Intuition, which is generally defined as thoughts that come to mind without apparent effort,(3) can be recognised in different phases of the diagnostic reasoning process.(4) This is indeed what the authors found after asking family physicians for 'occasions when they felt they knew the diagnosis or prognosis of a patient but did not know how they knew' (p.61). In our view their approach cannot lead to a 're-evaluation of clinical intuition' (p.61).

Secondly, we do not agree with the way the authors referred to our research results as if 'clinicians tend to describe their intuitions as gut feelings, admit not knowing their basis, and consider them irrational' (p.61). We reported that most family physicians considered their gut feelings a trustworthy compass, based on disease knowledge and experience.(4) Some GPs, however, regarded gut feelings as a pitfall which they tried to avoid by objective rational diagnostics.

Thirdly, we recognize the description of gut feelings in the results section. Recognitions and insights are based on intuitive knowledge via pattern recognition but the sense of alarm is based on a lack of pattern recognition: something does not add up here.(5) The sense of alarm may grow during the encounter, but might also have a sudden onset, after which it could fade away during the encounter.(4) Next to the sense of alarm we found another gut feeling, the sense of reassurance, meaning that a family physician feels secure about the further management and course of a patient's problem, even though he/she may not be certain about the diagnosis: everything fits in.(6)

Finally, in the discussion section, the authors took little notice of more embracing models of intuition in the literature that may explain all their findings within one concept.(1;2;5) Gut feelings, recognition and insights are based on the interaction between a family physician's knowledge and experience and the patient information available and may be understood by the interaction between analytical and non-analytical processes.(5)

References
(1) Hogarth RM. Intuition: A Challenge for Psychological Research on Decision Making. Psychological Inquiry 2010;21:338-353.
(2) Glockner A, Witteman C. Beyond dual-process models: A categorisation of processes underlying intuitive judgement and decision making. Thinking and Reasoning 2010;16:1-25.
(3) Kahneman D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol 2003;58:697-720.
(4) Stolper CF, Van Bokhoven MA, Houben PHH et al. The diagnostic role of gut feelings in general practice. A focus group study of the concept and its determinants. BMC Fam Pract 2009;10.
(5) Stolper CF, Van de Wiel M, Van Royen P, Van Bokhoven MA, Van der Weijden T, Dinant GJ. Gut feelings as a third track in general practitioners' diagnostic reasoning. J Gen Intern Med 2011;26:197-203.
(6) Stolper CF, Van Royen P, Van Bokhoven MA et al. Consensus on gut feelings in general practice. BMC Family Practice 2009, 10:66 2009.

Competing interests:   None declared

Woolley and Kostopolous' article on clinical intuition in Family Medicine indicates that experienced clinicians still rely on their intuitions as an inalienable component of clinical reasoning.[1] Their study is valuable in providing a rare empirical study of intuition as experienced by physicians, and identifying the cognitive processes active in medical decision making. It, therefore, provides an important contribution to the increasing literature on tacit-knowing in medicine. Woolley and Kostopolous identify three types of decision processes that may fall under the rubric of intuition: gut feelings, recognition and insight. Moreover, they note that "in all cases and process types, physicians talked about experiencing conflict between their intuition and another interpretation they considered more rational."[1 p. 63]

The question of human rationality lies at the heart of the issue of clinical intuition. The association of clinical intuition with irrationality has been entrenched by two major approaches towards statistical medicine, decision analysis and evidence-based medicine (EBM).

As is well known, EBM has relegated clinical intuitions to the bottom of their hierarchy of clinical evidence. The application of decision analysis to medicine tends to explore the manner in which intuitive thought processes and personal feelings may lead physicians and patients to make suboptimal medical decisions.[2] However, as Woolley and Kostopoulous indicate, the use of intuition by clinicians refers to other possibilities that are not accounted for in the epistemology of these two statistical disciplines. The question of the relation between clinical intuition and philosophical rationality requires a much larger analysis.[3] I do, however, have several brief comments about the tension between intuition and rationality in relation to this article.

Firstly, intuition is often associated with irrationality because of its inherent fallibility. However, the fact that an element of cognition is fallible does not mean that it is necessarily irrational. That clinical intuitions are fallible does not mean that they do not provide important information that cannot then be subject to further explicit scrutiny and logical analysis - what Daniel Kahnemann refers to as system 1 and system 2.[4]

Secondly, cognition refers to both conscious and unconscious processes. There is a bias not fully countered in Woolley and Kostopolous' article to refer to explicit conscious processes as rational, and implicit unconscious processes as irrational. However, as neuropsychologists increasingly recognize, a great deal of our cognitive processes are automatic or unconscious.[5] Models of human rationality, therefore, need to expand to include tacit-knowing, for example as described by Michael Polanyi in his theory of personal-knowing.[6] Physicians need to be educated that paying attention to clinical intuitions and hunches is not irrational. Introspection on their intuitions provides clinicians an invaluable means of relating empirical observations obtained through the senses with inner affective feelings, emotions, and not-yet conscious rational cognitions.[7]

Finally, besides its epistemological value, clinical intuition is normatively important in grounding clinical judgment as a moral enterprise. Clinical intuition, as I have argued elsewhere, is an important aspect of clinical reasoning modelled on practical wisdom or phronesis.[3] Clinical intuition provides the link between two embodied beings - doctor and patient. This value-laden relationship explains the moral feeling of unease in the presence of disease that does not fit the recognized patterns, and the sense of relief when the correct diagnosis is involved. Woolley and Kostopoulous hint at this affective/embodied aspect of intuition when they write that, "Judging intuitively is an emotional process whereby the judgment is felt."[1 p. 64] As embodied beings doctor and patient share a horizon of finitude and mortality that grounds the moral nature of their relationship. Clinical intuition presents the deepest clue about the nature of this relationship, and helps explain why it has not yet been superseded by technological advances.

References:
1. Woolley, A. and O. Kostopolou. Clinical intuition in medicine: more than first impressions. Ann Fam Med 2013; 11:60-66. Doi:10.370/afm.1433.
2. Redelmeier, D. A., Koehler, D.A., Liberman, and V., Tversky, A. 1995. Probability judgment in medicine: discounting unspecified possibilities. Med Decis Making, 15(3): 227-230.
3. Braude, H.D. Intuition in Medicine: A Defense of Clinical Reasoning. Chicago: The University of Chicago Press; 2012.
4. Kahneman, D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol. 2003;58(9): 697-720.
5. Lieberman, M.D. Social cognitive neuroscience: a review of core processes. Annu Rev Psychol. 2007; 58: 259-89.
6. Polanyi, M. 1962. Personal Knowledge: Towards a Post-Critical Philosophy. London Routledge Kegan and Paul; 1962.
7. Braude, H.D. Human all too human reasoning: comparing clinical and phenomenological intuition. J Med Philos. 2013; 38(2).doi: 10.1093/jmp/jhs057.

Competing interests:   None declared

You are probably right! The detailed interview method yielded very rich data with many potential avenues for research. However, our aim was to conceptualise clinical intuition in a way that would direct the application of cognitive psychological research to this area, thus the focus was on clarifying concepts for empirical study and hypotheses of process. It would certainly be interesting to see more interview studies of this sort with more analysis of content as well as process. Perhaps focussing on a single medical condition would be more appropriate for this though.

Competing interests:   None declared

Competing interests:   None declared