What About Intuition?
Intuition is frequently associated with the "art" rather than the "science" of medicine, notes Dr. Braude, and is perceived as biased or "fuzzy." But that doesn't invalidate the role of "tacit knowing" in the diagnostic process.
Dr. Montgomery distinguishes between "thinking slow," which involves using logic and data, and "thinking fast," which is a reflexive process more akin to intuition.
"There is a bidirectional relationship between these 2 forms of thinking when it comes to clinical diagnosis," Dr. Montgomery says. "The more knowledge and experience you have, the more fine-tuned your intuition will be. And the better your intuition, the more you'll know when and where to look for further information -- studies, guidelines, conferences, or collegial consultations."
Allan Katz, MD, gives an example of an intuitive hunch. "I checked up on a patient who'd just had bypass surgery and I noticed a rash on her neck. I referred her to a dermatologist, who was unconcerned. But some nagging feeling led me to refer the patient to a dermatologist at a cancer center, where she was diagnosed with lymphoma."
Still, intuition alone is not enough, says Kelli Harding, MD, Assistant Professor of Clinical Psychiatry, Columbia University Medical Center, New York, New York. "We owe it to our patients to incorporate validated measurement instruments into diagnosing psychiatric patients, rather than relying on potentially imprecise clinical impressions. Guidelines and algorithms lend objectivity and can be helpful road maps."
Consensus guidelines and algorithms have to be used carefully, Dr. Groopman cautions. He expresses concern that today's physicians are overreliant on evidence-based medicine. "While findings of controlled trials are valuable, they frequently don't translate into real-world practice, as applies to an individual patient," he comments.
He warns against rigidly applying consensus guidelines and clinical algorithms. "The temptation for time-pressured physicians is to seize upon the first bit of information the patient offers, plug it into an algorithm, and become anchored to single linear path rather than thinking independently and creatively."
But it doesn't have to be an either/or proposition. "Using measurement tools doesn't mean have to mean that doctor/patient interactions will become robotic, or that we'll stop using clinical judgment," Dr. Harding says. These guidelines are "mere basics that assure a minimally competent diagnosis," adds Dr. Montgomery. "They are at the bottom of the ladder and must be incorporated into a much broader diagnostic framework."
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Cite this: Are You a Great Diagnostician? - Medscape - Mar 27, 2013.