Intuition in Medicine is More Than a 'Gut Feeling'

Rachel Pugh

March 25, 2021

Alarm bells, a prickling on the back of the neck and a lurching in the stomach. All these terms are used to describe the ‘gut feeling’ or instinct, that some doctors may only admit to in private, that it can play a vital role in diagnosis, when faced with a patient with non-specific symptoms like fatigue or weight loss.

Dr Claire Friedemann Smith

Now researchers led by Dr Claire Friedemann Smith, from Oxford University, have published the first paper  in which GPs were selected because they had been clear on the referral form that their criterion for directing a patient into a cancer pathway had been gut feeling.

The qualitative study in the British Journal of General Practice interviewed 19 GPs who had referred a patient through the Oxford SCAN Pathway, a suspected-cancer pathway being used in Oxfordshire.

Unscientific but Rooted in Knowledge

An examination of their decisions revealed that GPs did not see their ‘gut feelings’ as unscientific, but rooted in knowledge, clinical experience, and in good relationships with patients, alerting them to the abnormal.

Dr Friedemann Smith told Medscape News UK: “What came out is that the ‘gut feeling’ is not the end of the process, but the beginning. It starts the process of ordering blood tests and ultrasounds that do not require hospital admission.

“We have shown how, rather than being used in isolation, gut feelings prompt evidence gathering and discussions with colleagues that can benefit patients with symptoms that don't easily fit with clinical guidelines.

“It prompts conversations with other doctors, especially if this is a young GP. In doing so they build up an evidence base to back up their original instinct.”

The team’s hope is that this study will prompt more research into the role of gut feeling. At present, many GPs do not have a way to fast track investigations for patients with 'non-specific' symptoms, according to the Oxford SCAN Pathway. Patients can go back and forth between their GP and the hospital many times until a diagnosis is made.

Research to date has been talking to GPs hypothetically and historically, but this research is the first to have used clinicians who have explicitly said they had used gut feeling in making a cancer referral.

Gut Feeling and Guidelines

The criteria used for the SCAN Pathway started as a trial sponsored by Cancer Research UK and has since been adopted as a standard of care in Oxfordshire and is run out of the Churchill Hospital, Oxford.

The same team, which also includes collaborators from the University of Aarhus, Denmark, is publishing research this summer into the reactions of the patients of the GPs in the study to the fact that 'gut feeling’ has been part of their management. Dr Friedemann Smith said: "Patients were generally supportive of their doctor’s use of gut feeling."

The use of gut feelings has often been described in primary care and by the National Institute for Health and Care Excellence (NICE) guidelines to allow GPs to refer patients for a scan if they feel there is a clinical need, even without 'red flag'’ symptoms, in recognition of a clinician's judgement. However, several clinicians spoken to by Medscape News UK for this article said they felt they would be criticised or even ridiculed for not being evidence based, if they talked openly about using them in practice.

One experienced clinical trainer at Manchester Medical School, and an advocate of the use of ‘intuition’, laughed when asked whether ‘gut feeling’ was ever mentioned when teaching her students. She told Medscape News UK: “No never, there would be shock, horror and recoil!”

Yet high-profile clinicians are prepared to champion its use. Atul Gawande, in his book Complications, describes an incident as a surgical resident, when he relied on his instinct when presented with a patient whose symptoms could have been either cellulitis or necrotising fasciitis. Both inflammatory conditions look identical in their early stages. His successful choice of diagnosis he writes"‘was not for logical reasons".

The law even recognises ‘gut feeling’ in the US. In his paper in The Journal of the Royal Society of Medicine, Salil Patel refers to Mueller vs Auker. In this case, a medical test was undertaken to aid diagnosis of a child against the parents’ wishes. The court decided that the doctor’s'‘clinical instinct' to undertake the test, took precedence over the parents’ fears.

One of the difficulties, in a risk averse clinical climate, is the difficulty of defining ‘gut feeling’. One participant in the Oxford University study, who had been qualified for 4 years described it as follow: "I think what we mean by gut feeling is...we’re drawing on physical signs, and little subtle features of the patient's behaviour…all of these things are just drawing on information all the time..And I think it has a role."

Fear of Ridicule

Many of the GPs said that they discussed gut feelings with their colleagues and in doing so were able to drill down to the gut feeling contributors, and sometimes provoked a similar feeling in their colleagues.

Even so, fear of ridicule and being considered unprofessional or ‘unscientific’ makes some UK clinicians unwilling to admit they use gut feeling or intuition. A doctor who qualified in 1990 told Medscape News UK: "There has been a horrendous shift to so called ‘evidence-based medicine', whose use has been distorted so that only certain types of 'evidence' are counted. Does any of this reflect Shipman and other enquiries?

“Sadly, you can’t protocolise the human body and systems have become overly rigid. Gut feeling counts in medicine. The human body is so complex, nuanced and not fully understood. The complexity of mind-body interactions can hardly be expressed. I wish that gut feeling/instinct/intuition had more of a place in modern medicine.”

Training in gut feelings is not an option, according to the new Oxford study. GPs felt that this was something that came from experience and could not be taught at medical schools. But Dr Friedemann Smith wonders whether it could be mentored and thinks it has a place in clinical practice.

She points out that the study only interviewed GPs who were open about using gut feeling, and that further research would be useful into those clinicians who do not consider intuition useful.

She said: “We think research is being hindered by the perception that gut feelings are airy fairy and unscientific. But we want to advocate for their more open use. If gut feelings are used more openly, then research into its use can be facilitated.”


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