Sick or not sick? This is the snap judgment all physicians make in the second they first view a patient. This is what they ask as they open the exam room door or pull back the curtain around the gurney. “Is this patient in front of me sick (in a way that means I need to act now to save their life) or not sick (ill but, someone I can patch up in some way and send home)?” Much of residency training is aimed at making sure young doctors leave with this skill finely honed. But, is it a skill or an innate talent that is hard to teach?
At the end of a recent clinic day I had just two patients left. I walked into the first room and inwardly groaned. This one was sick. However after hearing the history I started second guessing myself; it all sounded very reassuring. And, as we are also taught in medical school – the history is 90% of the diagnosis. Maybe I could treat and send this one home for the night? However, I had a gut sense, a hunch, that home was the wrong place for this child. That snap decision of sick won me over and I was right. The child was sick.
The next exam room held a child who I immediately felt was fine; not sick. But, the more I listened to their story the more I worried. There was some real potential for hidden danger. Then I was left wondering – how much of a workup should be done on this well-appearing child? Since the history had given me cause for worry, labs and a CT were done to prove that this child was indeed, not sick.
Later I commented to a friend on this sick vs. not sick judgment we make. He pointed out to me that likely this is based less in instinct and more in hard facts that are processed by our minds before we notice the processing. He felt that in a blink of an eye, on a subconscious level, I connected the dots I observed: reassuring history or not this patient was sick!
Perhaps but, I have met well-trained, intelligent doctors who struggle with this talent of intuition. In medicine the hard facts are obviously of tantamount importance but, our instincts need to complement our intelligence. Malcolm Gladwell wrote in his book Blink: The Power of Thinking Without Thinking:
The key to good decision making is not knowledge. It is understanding. We are swimming in the former. We are desperately lacking in the latter.
Another friend of mine is in the process of making a life-changing decision. His sister challenged him by asking how he could make such a choice with barely any evidence of it being right? He explained that it felt right, that his gut told him it was right, that to make this choice made him feel like he was returning to home. Gladwell might say to his sister that:
our world requires that decisions be sourced and footnoted, and if we say how we feel, we must also be prepared to elaborate on why we feel that way…We need to respect the fact that it is possible to know without knowing why we know and accept that – sometimes – we’re better off that way.
In his 2005 commencement address at Stanford, Steve Jobs spoke in large part about trusting one’s intuition both in career and in love.
you can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something — your gut, destiny, life, karma, whatever.
I wonder what Jobs would make of this concept of the balance of science and intuition that physicians face with every patient? In our personal lives it is clear he felt trusting our gut was the way to go. He left those Stanford graduates with wise words:
have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.