The Gut Feeling

Published on July 13, 2015
A new EM resident explores the ins and outs, and the basic neuropsychology, of becoming a professional decision maker especially in the ED.

When I began my residency in the ED I felt like jumping in at the deep end. Coming from internal medicine, a world of structured visits at fixed times with clear hierarchies, the somewhat chaotic and informal environment in the ED fascinated me. Noise, overcrowding, frequent interruptions, limited patient information, and constant time pressure didn’t bother me a lot. I quickly realized that the biggest challenge for me would be dealing with the huge number of decisions one had to make. There were so many questions I had to deal with, starting with triage, diagnostics, therapy, in- or out-hospital treatment, admission to which department, involvement of other specialists—just to mention a few. Many of these questions were new to me, and my existing knowledge seemed to help little. I had to develop some decision-making skills, and fast.

By analyzing and trying to copy my senior physicians, I soon realized that there were big inter-individual differences concerning these skills. For example, there were risk takers and precautious types, some relied on their clinical skills, others ran lots of imaging, yet others always asked for specialist support. In many Swiss hospitals, the ED is still subdivided into internal medicine and surgery. So as a resident, you work with senior physicians with very different backgrounds and emergency medicine experience, which also reflects in their decision-making. However, one thing was universal to all the attendings I was working with: most of the time, their decisions weren’t based on textbook knowledge; they were often just made based on gut feeling and clinical rules of thumb. Until then, being an evidence base-drilled internal medicine resident, I hadn’t been aware of this particular dimension of medical work, and I wanted to understand it better in order to improve my decision making skills.

First, I had to get an idea of how my brain copes with the large amount of information it is being confronted with. This would help me understand how I assess a patient.

The main information processing strategy is probably pattern recognition, which is the basis for everything from doorway diagnosis to gut feeling. Take herpes zoster, for example, which is for most of us a doorway diagnosis. When I learned about herpes zoster for the first time, I had to consciously define the characteristics of the rash and to distinguish it from other differentials. This was a conscious, analytical, time- and energy-consuming process. With repeated exposure to this diagnosis, however, my brain felt convenient and safe enough to automate the processing of information and to massively accelerate it by doing so.

Pattern recognition plays an equally important role in complex patient presentations because of its associative characteristics. Our brain always subconsciously and automatically tries to interrelate the information it processes. So this interrelation of patterns allows experienced physicians to group information like disease-related history, physical examination, and laboratory findings. Thus, the greater the experience, the greater the collection of patterns we can work with. The subconscious association of these patterns also allows us to capture the patient’s condition at a glance. We call this phenomenon gut feeling. During the years of my residency, I understood that one of the biggest differences between individual emergency physicians is the extent to which they rely on their gut feeling.

This interplay between pattern recognition and use of heuristics is indispensable for fast patient assessment and triage. From the moment I realized this, my metamorphosis from internist to emergency physician began.

My second step to improving decision-making skills was to understand the role of clinical rules and mental shortcuts.

In emergency medicine, we love clinical rules of thumb and use them to a much greater extent than other specialists do, because most of the time we are forced to assess patients without having the full picture and complete information. The missing information is replaced by assumptions that are based on our experiences, prejudices, beliefs, and superstitions. These strategies are also known as heuristics. An alternative use of heuristics is to just intuitively ignore irrelevant information and, in so doing, speed up the diagnostic process. So, is less information sometimes more? Just imagine a typical patient with a renal colic. Having recognized this particular pattern, experienced emergency physicians would probably choose the most direct way to diagnosis without actively considering all the differentials of acute flank pain, and by looking for evidence that supports their assumption. This interplay between pattern recognition and use of heuristics is indispensable for fast patient assessment and triage. From the moment I realized this, my metamorphosis from internist to emergency physician began.

Of course, not all patients will fit into a known pattern, forcing us to step back and still think analytically. We ask ourselves what the patient could have, we make a list of differentials and try to prove them with tests. We make use of the hypothetico-deductive strategy. This is a more accurate and conscious way of processing information, but it also expends a lot of our cognitive capacity. But even here, we are not strictly analytical as human beings. Our top list of differentials reflects not only the prevalence of a disease with the given symptoms but we also consider some diagnoses disproportionally prevalent: those more readily available to our mind, those that are more easily treated (we intuitively don’t want to miss those), and those that are serious. Depending on the seriousness of the differential, we might even choose the “rule out the worst” strategy before we continue testing other hypotheses. So in clinical reality, we still use this rational strategy in our naturally irrational way.

As a young resident, I always felt a mismatch between the way we make decisions and the way we explain them. Sometimes, when I tried to rationalize the irrational, it led to misunderstandings with supervisors. Those were the moments when I thought, “If you would just see the patient, you would understand what I’m talking about.”

Today, as a young attending, I accept the gut feeling as an argument, and I think that we should try to sensitize the residents for this dimension. In countries like Switzerland, where we try to emancipate emergency medicine, we should actively teach heuristics and emphasize their importance for our specialty. Further investigation in the field is needed, and, with more knowledge, we could perhaps one day even make adjustments to the workflow in EDs, making it more adaptable to our evolutionarily derived intuitive skills, with all their capabilities and limitations.

The online version of article was amended on July 16, 2015 to correct two editorial errors.

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