Medical matters: Should doctors listen to their gut instinct?

What would you rather have, a doctor who uses professional intuition or one who sticks rigidly to guidelines? It’s a topical question and one that was addressed at last month’s annual TedMed conference by Robert Wachter, professor of clinical medicine at the University of California, San Francisco.

Professional intuition – the gut feeling doctors get from experience and instinct that something isn’t right – is under assault, he told the audience.

“It’s suspicious, it’s soft, it’s squishy,” he explained. “There’s not an algorithm for it, it’s not evidence- based.” And he reckons medical intuition is sometimes seen by the public as antidemocratic and paternalistic. Indeed, for some it may signal a return to the bad old days of God-like doctors who enjoyed being placed on a pedestal.

As someone who is comfortable using professional intuition, I would hate to see it hounded out of existence. In fact, it can be a hugely constructive force in the consultation if openly shared with your patient. Used judiciously and in a consulting style that encourages questions from patients and making shared medical decisions alongside them in a collaborative way, I would venture to say that medical intuition is a powerful force for good in healthcare.

But Wachter is right to warn of a threat. It comes primarily from evidence-based guidelines which have, in many cases, morphed into rigid and prescriptive instruments. This has made some of these guidelines unworkable in everyday practice.

Worse again, when adopted by governments, guidelines are in danger of promoting a “tick-box” style of medicine that has more to do with maximising physician income than offering holistic patient care.

Objective tests

But there is an even more basic problem with guidelines: their quality is variable and nearly all fail objective tests of their dependability.

A 2013 study in the Journal of the American Medical Association (JAMA) assessed a number of guidelines on the basis of eight standards for creating guidelines set by the Institute of Medicine (IOM). Not a single one of them met all eight standards. In separate research from 2012, barely one-third of guidelines produced by subspecialty societies satisfied more than 50 per cent of the IOM standards.

Writing in the online journal Medscape earlier this year, emergency physician and attorney William Sullivan said: "Guidelines may be outdated, too general, too vague, or too narrow." He pointed out that a guideline may apply to "uncomplicated" cases, which may not reflect the reality of patients with multiple diseases. "Or there might be a lot of qualifiers, and you would have to follow all of them to the letter, and in the end they may only apply to a small group of patients."

Intuition isn’t solely based on experience. It is a process of non- linear thinking and the cultivation of a sixth sense. And, while I appreciate it can approximate to professional paternalism at times, that is not the doctor’s intention. As long as he or she is empathetic, listens well and engages in shared decision-making, a doctor can incorporate medical intuition to benefit the patient.

Guidelines, on the other hand, are based on evidence garnered from populations in order to define the most likely presentation and outcome of a disease. But population health cannot be allowed trump the unique experience of the patient sitting beside you.

In an age of remarkable technology, the democratisation of healthcare and a welcome desire for patients to do more for themselves, will doctors eventually lose their utility? Not as long as society sees a value in having a trusted and caring expert who helps people to navigate through the complexities of modern medical science.

Wachter was asked whether computers will ever replace doctors as diagnosticians. “Maybe,” he said. “They’re not there today, and I don’t believe they will be there in the next few years. I suspect they’ll get there when computers learn to write award-winning poetry, to skate in the Olympics, and become the chief executives of Fortune 500 companies.” mhouston@irishtimes.com @muirishouston