Doctors who trust their gut, vs doctors who order more tests

Would you like to be treated by a doctor who relies on his gut instinct? And have you ever found yourself introducing a completely new symptom or concern just as you were leaving the consultation room?

The link between these apparently random questions lies at the heart of medicine as an art rather than a science. While the principles of modern medicine are rooted in science, its practice can be a more subjective exercise. And not in a bad way, I hasten to add.

I have used medical intuition throughout my professional life. It’s not always correct, of course, although on a number of occasions it has led to an early diagnosis of cancer in a patient. But as a proponent of narrative medicine and reflective practice, following gut feelings is something I’m definitely comfortable with.

A recent study has highlighted the important role human intuition plays in medical decisions. Scientists at the Massachusetts Institute of Technology (MIT) analysed 10 years of data on patients in intensive care and found that doctors’ gut feelings about how their patients were doing influenced how many tests they ordered.

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The researchers collected information on all factors a doctor might consider in deciding to order tests, including a patient’s age, disease type and severity. They also measured doctors gut feelings about their patients by analysing patient notes using an algorithm that scores text for positive and negative sentiment.

Pessimistic

When doctors were more pessimistic about a patient’s condition, they tended to order more tests – but only up to a point. If they felt very negative about the patient’s prognosis, they ordered fewer tests. This effect was strongest at the beginning of a patient’s hospital stay, when doctors had less medical information to go on, and declined over time.

The MIT study is especially relevant in explaining why there can be so much variation in the use of medical resources. And at a time when tick-box medicine threatens to rule healthcare, feeding into a model beloved of administrators bent at cutting costs whatever the consequences, it’s a suitable reminder of why time spent with patients trumps formulaic care every time.

A paper in the Journal of General Internal Medicine concludes that the earliest impressions a doctor forms when confronted with a problem are often more accurate than a later analysis. A BMJ paper found that a doctor's gut feeling that something was wrong when treating a child in primary care can have greater diagnostic value than many signs and symptoms. Interestingly, in this study, the level of clinical experience didn't seem to matter; a doctor's intuition about a child's condition was primarily influenced by how much the parents were concerned, but when it came to the diagnostic value of the gut feeling, the clinician's level of experience made no difference.

Empathy

It appears medical intuition may have more to do with empathy than expertise. Family doctors who scored highest on empathy were four times as likely to report using gut feelings in practice compared to those who scored lowest on empathy.

Meanwhile so called “door handle” consultations are another subjective phenomenon in medical practice. Typically, the issue of apparent primary concern to the patient has been dealt with comprehensively, when, on the point of exiting the room, the person says “Oh by the way doctor...” In some cases, these late interventions have been shown to be the real reason for the consultation-only for the person, for reasons including anxiety or embarrassment, to present with an entirely different problem at the outset.

Doctors are trained to swallow feelings of frustration about the effect of dealing with a new gambit will have on their appointment schedule. But it is the art of medicine – in the form of finely tuned empathy – that determines whether the new symptom requires an immediate prolongation of the consultation or an invitation to make a separate appointment.

That’s not something a robot will ever achieve.

[ mhouston@irishtimes.com ]