Clinicians and their spidey sense

The patient was 35, pregnant, diabetic and a methamphetamine user. Almost from the moment she was admitted to the hospital, Dr. Theresa Chan had an uneasy feeling this was a patient headed for serious trouble.

Scrambling to do rounds on her other patients and taking a quick glance at the woman’s X-ray, Dr. Chan’s unease grew. Although the ER physician who admitted the woman to the hospital gave a preliminary diagnosis of pneumonia, Dr. Chan had some doubts and decided to see for herself.

Her blog describes what happened next:

As I walked into her room, I felt a hair on the back of my neck rising up. Not literally, of course. The hair – and it is only one – has become the symbol for the feeling I get when a patient is really sick. It sprouted during the second year of my residency and has been with me ever since.

To make a long story short, the patient turned out to have inflammatory fluid that had collected in one of her lungs and developed an infection. She could hardly breathe. Within the hour she had a chest tube inserted by a surgeon. She ended up being transferred to a tertiary care center and ultimately lost the pregnancy.

“The moral of this case: Whatever anyone tells you, check the facts for yourself,” Dr. Chan concludes.

Do clinicians have a spidey sense, like the comic-book superhero Spider-Man, that tells them when something is really wrong with a patient?

The pitfalls of relying on perception are outlined in an interesting analysis published online last month in the Journal of General Internal Medicine. It examines a specific area of clinical practice: judging whether a patient is truly getting better in response to treatment.

How do you know the patient is improving? Is this an assessment based purely on test results? Is it based on how well the patient looks? Is it a combination of objective measurements and gut instinct? And how do you avoid misjudgments due to overconfidence, memory lapses, unspoken assumptions and other thought processes that can cloud one’s thinking?

There’s a intriguing role played by clinical intuition – the gut sense, often based on a vague combination of sight, sound, touch and past experience, which helps clinicians recognize when a seemingly minor problem might actually be much more, when the diagnostic facts don’t add up – perhaps even when the patient is a faker or a drug-seeker.

Is it the real deal? Clinical intuition is a somewhat controversial concept in medicine. It’s not clearly defined and it’s not something that’s part of any formal training curriculum. It seems to be more well developed in some people than others, although few clinicians are willing to follow their intuition alone, without objective facts to back it up. And as the journal article demonstrates, gut instinct can be prone to all sorts of cognitive errors.

Yet the spidey sense seems to be genuine, even if it’s hard to pin down. ‘I know it absolutely exists and I am happy to have a decent dose of it,” writes the anonymous ER nurse who blogs at Not Nurse Ratched.

So what is spidey sense? “Your patient just looks wrong. Or DOESN’T look wrong, but you have a gut feeling that something is about to go seriously wrong,” she writes. “Generally, and this is really the point of my post, you’ve got nothing to hang your hat on as far as an assessment finding or anything from the patient’s history, and that makes spidey sense problematic.”

Sometimes the spidey sense generates a false alarm but better to be safe than sorry, she concludes. “If the patient doesn’t look quite right and that’s all I’ve got, I use it. I feel a little silly, but I do.”

Various studies have taken a closer look at the role of intuition in medicine. Empathy, for instance, may be partly intuitive, although there’s still a fair amount of debate over the extent to which it’s innate vs. a skill that can be taught. A small study conducted in 2007 found that nurses often use intuition in their decision-making, and that their use of intuition tends to increase with experience. (The study didn’t analyze how often the nurses’ intuition turned out to be correct, however.)

“Do we need evidence for everything?” wonders Dr. David Hunter in a 2010 American Orthoptic Journal article that questions the assumption that objective, measurable evidence should underlie all medical decisions. “The frequent lack of solid clinical evidence requires clinicians to invoke critical thinking, communication, judgment, and even intuition on behalf of their patients. Medical training is as much an apprenticeship as it is an education, and medicine as much as craft as it is an art.”

Evidence does matter; clinicians can’t make good decisions if they lack facts or knowledge. But it seems there’s a place for intuition as well, even though there’ll likely be debate for years to come on how reliable the spidey sense truly is.

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