Clinical intuition has long been a debated topic. To date, there is still no accurate definition. It’s been said that experienced, older physicians more commonly rely on clinical intuition, whereas novices prefer evidence-based medicine. How many of us have had that “gut feeling” point us toward a decision that did not follow a rational explanation in the management of a patient?
The first time I met my patient was during an initial visit that was inappropriately booked for a 20-minute slot. This only gave us time for brief introductions and then to address her main concern of getting her medications refilled that day. We scheduled a wellness visit in a few weeks’ time and agreed we’d catch up then.
Four months later, her chart was brought to me with the words “chest pain” written on it.
I looked up at my list, seeing in bold and red the double-booked slots amid what felt like a never-ending list of patients scheduled for my morning session. I was already behind schedule. I felt exasperated, like I was sprinting and jumping over hurdles trying to catch up with the workload. It was my first year as a PCP working in a community clinic.
I walked into the room and found her sitting comfortably in the examination chair. That’s a good sign, I thought. I sat down and started chatting with her. She told me she had left-sided chest pain, and also felt it in her back. However, the pain was completely resolved on the day of our encounter.
As she told me this, something about her facial expression made it seem as if she was reassuring herself that the chest pain wasn’t anything serious. I could see the worry in her eyes, despite her smile. I immediately had a “gut feeling” that this wasn’t just muscular chest pain. Her physical examination did not reveal any abnormalities. She was in great shape for being in her 80s. In fact, I recall double-checking her age during the first visit. Her EKG was normal.
OK, so there’s nothing acute; she appears stable. It's OK to send this patient home with some further outpatient workup. But why don’t I feel comfortable doing this? Just a gut feeling, a hunch? Clinical intuition? Could this be aortic dissection?
I had evaluated patients in the clinic with chest pain daily, most had been noncardiac in origin. During my residency training, the patients with acute aortic dissections whom I interacted with were all more acutely ill.
Again, I told myself, There’s nothing emergent, why should I send this patient to the ER. Should I risk making her get a bill for an ER visit? I am her PCP; I should try to address this in the outpatient setting. Did I really want to send an 80-year old to the ER during a pandemic because of clinical intuition? With the practice of medicine increasingly transitioning away from clinical intuition toward evidence-based medicine, I wondered, What kind of doctor am I?
I sat at my workstation and deliberated for several minutes, looking up at my patient list again, now with several patients roomed and waiting to be seen. At that point, I wished I could request a cardiology consult on site, or even get a chest X-ray. But this was a community clinic, and no cardiologist was in the practice.
I just could not, for some reason, let this patient go home, and I couldn’t explain it at the time. So I decided to send the patient to the ER.
I took a deep breath and walked into the room. I explained to the patient that I was worried that her episode of chest pain may be something more urgent and that it could be dealt with best in the ER. She willingly agreed to go to the ER to get further evaluation. After all, I was her doctor, and she trusted my recommendations. At that point, I felt as if I didn’t trust myself for sending this patient to the ER on clinical intuition alone. Impostor syndrome weighed heavily on me.
The next day, I checked her chart. She was diagnosed with early aortic dissection and was scheduled for repair. The feeling of relief I felt — that I didn’t send this patient home where she could have further decompensated — is indescribable.
Reflecting on my decision-making process with this particular case, and asking myself why I made the decision to send the patient to the ER rather than pursue outpatient workup, motivated me to look at the literature on clinical intuition. I had incorporated the generalizable research (patient with chest pain, history of smoking, the low validity of physical signs in the elderly female patient who can present with atypical chest pain) with the ones specific to this case (her concerned look, indicating to me that the episode of pain was severe). At the time of my decision, I was not conscious of my “trend of thought” and had never really paid attention to my complex decision-making process when with patients. It had become so automatic, especially with the outside pressure to see more patients in less time.
This self-reflective approach to patient care has helped me identify several areas of ambiguity in both the decision-making process as a clinician and the application of evidence-based medicine practice in the management of complex cases.
There is no properly developed educational method for clinical intuition, and it is also very difficult to evaluate. However, with demand rising for expert thinking in the field of medicine, understanding how to monitor one’s knowledge base continuously, together with the application of contemplation, deliberation, and intuition when faced with unfamiliar clinical cases, is invaluable. This metacognitive approach may serve as a platform for combining both clinical intuition and evidence-based medicine in our daily practice.
Share your thoughts on the pros and cons of relying on clinical intuition in the comment section.
Sobrina Mohammed, MD, has been an assistant professor of internal medicine and a primary care provider with a passion for teaching at University Health Truman Medical Center, Kansas City, Missouri for the past two years.
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