Feeling in the gut or thinking in the brain..?

No more than a couple of days go by without someone around me using the phrase “gut feeling”, not just in a healthcare context but in all aspects of life. Sensing something, without the information you would normally use to draw conclusions, is a part of human nature.  Whether a gut feeling about the weather, someone’s state of mind or your decision to buy a car, our ‘intuition’ is an constant factor in our decision making.

gut feeling

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There are many ways to describe Tacit Knowledge (Schon described it as “usable but difficult to express”). In healthcare the term gut feeling is used extensively; almost every morning handover someone says, “I wasn’t sure why I did this – it was just a ‘gut feeling'”. Given that the cognitive theory behind intuition and decision making has been well researched (see this great review by Javier Benitez from ALiEM) it is interesting that the term  ‘gut feeling’ itself has been relatively poorly explored in medicine. This is even more surprising given the increasing awareness of the cognitive errors that clinicians make. Pat Croskerry has written some brilliant articles on the subject.

Gut feeling has inherent anecdotal appeal because of its face validity. We have all experienced a gut feeling about something so it makes sense that it is real ‘thing’ in the clinical world. Published literature supports this and in a large primary care setting Van den Bruel and colleagues examined the gut feeling of General Practitioners (Family Doctors) in respect to the examination of unwell children. They used the following definition:

“Gut feeling was defined as an intuitive feeling that something was wrong even if the clinician was unsure why; we recorded this feature as either present, absent, or unsure”

In this study doctors’ intuition did seem to correlate with an increased risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) but this is in the context of 3369 children being part of the study with only six (0.2%) admitted to hospital with a serious infection.

To me the key point of this study was the recognition by the authors that:

such intuitive feelings might arise from the condition of the child (for example, a feeling that the child was unduly lethargic despite a lack of localising signs) or the behaviour of the parents (for example, a feeling that the mother was unusually anxious compared with previous consultations).”

I think this is key because gut feeling is often used in the in the context of recognising illness – deciding when to treat a patient when others may not have done – but equally important is the converse; the decision not to treat when others would. Actually this is a really important gut feeling.

As a clinician specialising in Paediatric Emergency Medicine I often decide to observe patients (my maxim in paediatrics is that “observation is an investigation”) and this often includes those children who on paper look moderately unwell but for whom I have a gut feeling that their distress will improve with analgesia (paracetamol or ibuprofen given as a treatment for distress, not as an antipyretic). I sometimes have no objective idea why I am doing this and often have to reassure juniors that they wouldn’t have been incorrect had they decided to start working the patient up, but that I am taking clinical responsibility for this decision. And my judgement is pretty often correct which can become an uncomfortable feeling. I wonder if other clinicians worry that their gut feeling has been correct for too long.  Is an inevitable mistake just around the corner? There are certainly arguments that relying on gut feeling may not be good.

The other important distinction to be made here is that gut feeling is not simply enhanced clinical acumen. I have a gut feeling about a patient despite the clinical information presented to me, not because of this information. Juniors may be impressed that I can tell someone is hypoxic just from their cough but this is not gut feeling. I have spent years listening to asthmatics booking in at reception desks and know what a child with obstructive lung function and low SpO2 sounds like. This is just pattern recognition and it can be learnt and developed over time. It is equivalent to the observation that few healthcare professionals need gut feeling to tell you that a critically unwell patient is critically unwell; it is often obvious to everyone.

However it is probably fair to say that, before I realised I was using clinical  information in this way, I did think it was gut feeling. This may be why there is a belief that you use gut feeling more as you become more experienced. Could it be more the case that you just become better at realising why you are making some decisions (an odd sort of enlightened unconscious competence) and so decisions based on gut feeling seem more relevant?

The ability to distinguish between your clinical acumen and gut feeling is a complex task and I have a gut feeling its going to be a long time before we fully understand it. It would be great to hear of your examples of gut feeling used to full effect..! But I think everyone should stop and think the next time they think they use gut feeling. Was it really gut feeling or is there something that you noticed that could be taught to others?

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Damian

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Post blog note:

Some other Croskerry Papers on cognition:

http://www.jround.co.uk/error/reading/crosskerry1.pdf (croskerry paper)

http://www.ajustnhs.com/wp-content/uploads/2012/10/croskerry-better-decision-making-2011.pdf

http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf

 

 

10 Comments

  1. Jo Deverill

    You have nailed it. Gut feeling is subconscious pattern recognition – of facial expressions, movements, sounds, behaviour. It’s not your gut doing this of course, but parts of the brain that may not be well connected to speech. (Who knows they may be better connected to your gut than to Broca’s area.) So by its very nature, gut feeling is difficult to convert into words. You’ve done a great job of explaining that here.

    Reply
    1. Dr. Damian Roland

      Thanks Jo – I like the concept of being better connected to your gut than brain on a truly neuro-physiological sense as well!

      Reply
  2. Toby Hillman

    A key tip for new junior doctors is to work out which Sister or Charge Nurse is right when they say ‘I’ve got a feeling about x’ and remember to run if they ask for help.

    This ‘nurses intuition’ is similar to what you describe – a wealth of experience distilled into accurate pattern recognition of unmeasured clinical information.

    Reply
    1. Dr. Damian Roland

      Thanks Toby – would be interesting to know if different health care professionals use different constructs to guide their intuition or principles are the same for everyone?

      Reply
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