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Psychology

Is it time to embrace intuition as a key part of clinical decision making?

What’s your reaction to the word ‘intuition’ when it comes to clinical care? I imagine some of you may believe that your gut feelings can usefully support your decision making, and others will perceive it as irrational and dangerous. And many of you will be somewhere in between.

In this article I will be exploring the concept of intuition and whether it might be useful or dangerous in clinical care.

The science behind intuition

Over recent decades, psychologists have sought to understand and describe the basis for human judgment and decision making. The consensus seems to be that we have two systems in place, broadly described by ‘dual process theory’. 

Renowned psychologist Daniel Kahneman described these two systems as fast and slow thinking. System 1 is fast, intuitive and driven by instinct and prior learning. System 2 is slower and more logical, rational and analytic. 

System 1 operates automatically and quickly, with little or no effort and no sense of voluntary control. Examples include turning to the source of a loud noise, detecting emotion in a voice, and understanding words in our language. Other animals have a System 1 process too, allowing them to quickly recognise objects and perceive dangers.

System 2 is more recent in terms of evolution and is highly developed in humans. It concerns activities that require more mental effort and attention. Examples include looking for a friend in a crowd, doing mental maths, or working to stay calm when you feel angry. 

We have the ability to come to conclusions based on very little information, and these spontaneous decisions are often as good as, or even better than, carefully planned and considered ones.

Kahneman explains that when working together, System 1 provides suggestions for System 2, such as impressions, intuitions, intentions and feelings. If all seems well, System 2 will adopt these suggestions with little or no adjustment. When System 1 runs into difficulty and cannot provide an answer, it calls on System 2 for more detailed processing.

And this collaboration works well most of the time because – in general – System 1 is pretty accurate. The assessment of familiar situations, short-term predictions and initial reactions to challenges are usually appropriate. This system allows us to process complex information quickly and avoid our brains getting overloaded. 

In his book Blink: The power of thinking without thinking, author Malcolm Gladwell agrees: he suggests that sometimes having too much information can interfere with the accuracy of a judgment and lead us into ‘analysis paralysis’. He provides examples from a variety of sources including medicine, advertising, dating and sports to demonstrate that we have the ability to come to conclusions based on very little information, and that these spontaneous decisions are often as good as, or even better than, carefully planned and considered ones. 

Gladwell and Kahneman both agree, however, that these ‘snap judgments’ made by System 1 are prone to biases, of which there are many. This is when we stereotype, overestimate, and are notoriously bad at understanding risk and probabilities. 

Most humans like to identify with System 2 – logical, rational, conscious, and actively making choices and decisions. But System 1 is providing the initial impressions and feelings that are the main sources of the beliefs and choices made by System 2. 

System 1 can be instinctual (babies turning their heads towards noises), but it can also be based on learned experience. For example, previously effortful activities can become System 1 activities when highly practiced: driving a car or handwriting, for example. 

Whether this is true in more complex environments is less clear. What is likely is that we learn to recognise a pattern which, over time, will give way to a System 1 rapid assessment, and we then consult System 2 for more information.

The role and value of intuition in health professionals

The role and understanding of intuition in clinical decision making is only just starting to emerge.

In a literature review and content analysis, Swedish researchers found that intuition plays a key role in more or less all of the steps in the nursing process as a basis for decision-making that supports safe patient care. They conclude that intuition is more than simply a ‘gut feeling’; rather, it is a process based on knowledge and experience. They found that nurses integrate intuition alongside objective data when making decisions. The authors support a place for intuition beside research-based evidence and suggest that nurses should rely on their intuition and use it to support decision-making to increase the quality and safety of patient care.

Over in Belgium and the Netherlands, a qualitative study of 28 hospital doctors found that intuitive knowledge played a recognisable role in quick assessments of the seriousness of a patient’s situation. Amongst these doctors, intuition acted as a guide in the diagnostic process or as a trigger for further exploration, making fast decisions possible when needed and reducing unnecessary investigations. All participants reported that their intuition was an important tool for starting the diagnostic process, but that they followed up with more analytical reasoning before reaching their final diagnosis. However, most participants agreed that their first hypothesis, based on intuition, usually did not differ much from their final diagnosis. 

Dutch researchers investigated intuition further in a focus group of GPs where they found predominantly two types of gut feeling when it came to dealing with patients: a sense of reassurance and a sense of alarm. GPs in this study reported that they feel a sense of reassurance when they are sure about the prognosis and therapy, although they may not always have a clear diagnosis in mind. A sense of alarm means that a GP has the feeling that something is wrong even though objective arguments are lacking. This sense of alarm is often accompanied by a physical sensation in the abdomen or the heart. GPs in this study reported that their intuition acted as a compass in situations of uncertainty and the majority of GPs trusted this guide.

UK researchers pulled evidence together to conduct a systematic review around the role of gut feelings in GPs’ ability to diagnose cancer. They concluded that a cancer diagnosis was more likely in patients for whom the GP had a gut feeling compared with patients for whom the GP experienced no gut feeling. They conceptualised GPs’ gut feelings as a “rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs’ knowledge and experience.” Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience, but they remain poorly recorded and inaccessible to researchers. They suggest that it is possible that gut feelings triggered by clinical features outside of cancer guidelines highlight the limitations of current referral criteria.

There seems to be no published research on the role of pharmacists’ intuition in providing care to patients. However, one pharmacist contacted me in response to my request for examples. Here’s her experience: 

Mehreen Karim was a Band 7 pharmacist in a mental health Trust. She had been looking after a patient in the hospital whose health had suddenly declined. Mehreen looked through notes, medical assessments and observations and found anomalies: “it just didn’t make sense, it didn’t feel right”. 

Based on this uneasiness, Mehreen investigated further and looked carefully at blood results, renal function and sodium levels and, together with her consultant, diagnosed the patient accurately.

Mehreen told me that this event made her realise how valuable her intuition is, and she continues to trust this instinct to prompt her to keep exploring when things don’t add up. 

Do you trust your intuition? 

Going back to the question at the beginning of this article: What’s your reaction to the word ‘intuition’ when it comes to clinical care?

We’ve seen that intuition can be explained as a fast-track system of information processing and decision making. We know that it can be honed by experience and knowledge, and we know that it is often accurate, albeit sometimes prone to biases. And we’ve seen evidence that clinicians self-report using it in practice alongside more analytical methods to aid decision-making in patient care. 

But do you trust your intuition? Do you admit to your colleagues that your clinical decisions are in part based on your gut feelings?

All the hospital doctors in this study recognised intuitive knowledge in their diagnostic reasoning process but admitted“some of us are very allergic to the word ‘gut feelings’. They think that as a doctor you can’t use that term. But at the same time, I think that everyone knows that it does exist.”

My final question to you, therefore, is: Can you embrace intuition as a key part of your clinical decision making?

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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Intuitive knowledge sounds more acceptable somehow than gut feeling – even though we probably understand gut feeling better! Thanks for this, very interesting.

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