A Country Doctor Writes:

“The young man knows the rules, but the old man knows the exceptions.”

Oliver Wendell Holmes, Sr., M.D.

I have been reading from two e-books lately on my new iPad. One of them, a bestseller published in 2005, is “Blink”, subtitled “The Power of Thinking Without Thinking” by Malcolm Gladwell. The other book, digitized by the Gutenberg project and first published in the late 1800’s, is “Medical Essays 1842-1882” by Oliver Wendell Holmes, Sr., physician, Harvard dean, poet and friend of Emerson and Longfellow.

As I read along I realized the two works both happened to address what clinical instinct really is, compared with pure book-knowledge, a question that is more important now than in recent memory as we strive to digitize and standardize every aspect of the practice of medicine.

In our decade, Gladwell, a British-born, Canadian-raised writer for “The New Yorker”, writes about the value of our subconscious calculations, which are faster and more accurate than our conscious, logic-based, conclusions. This applies also in medicine. Gladwell writes on his website (http://www.gladwell.com/blink/):

“One of the stories I tell in “Blink” is about the Emergency Room doctors at Cook County Hospital in Chicago. That’s the big public hospital in Chicago, and a few years ago they changed the way they diagnosed heart attacks. They instructed their doctors to gather less information on their patients: they encouraged them to zero in on just a few critical pieces of information about patients suffering from chest pain–like blood pressure and the ECG–while ignoring everything else, like the patient’s age and weight and medical history. And what happened? Cook County is now one of the best places in the United States at diagnosing chest pain.”

In “Blink”, Gladwell describes how professional gamblers start avoiding cards from a stacked deck as their biometric parameters, like skin temperature, register stress, long before they consciously become aware of what is occurring.

150 years earlier, in the essay “The Young Practitioner”, Holmes wrote about clinical instinct in the experienced physician:

“Book-knowledge, lecture-knowledge, examination-knowledge, are all in the brain. But work-knowledge is not only in the brain, it is in the senses, in the muscles, in the ganglia of the sympathetic nerves,—all over the man, as one may say, as instinct seems diffused through every part of those lower animals that have no such distinct organ as a brain. See a skilful surgeon handle a broken limb; see a wise old physician smile away a case that looks to a novice as if the sexton would soon be sent for; mark what a large experience has done for those who were fitted to profit by it, and you will feel convinced that, much as you know, something is still left for you to learn.

The young man knows the rules, but the old man knows the exceptions. The young man knows his patient, but the old man knows also his patient’s family, dead and alive, up and down for generations. He can tell beforehand what diseases their unborn children will be subject to, what they will die of if they live long enough….The young man feels uneasy if he is not continually doing something to stir up his patient’s internal arrangements. The old man takes things more quietly, and is much more willing to let well enough alone: All these superiorities, if such they are, you must wait for time to bring you.”

I have seen many examples of situations when you simply can’t get caught up in all the details of history taking and physical exam. Clinical observation, where all the physician’s senses become involved, can be faster and safer. Our whole reimbursement system, however, rewards doctors for asking lots of questions and evaluating as many (even irrelevant) body systems as possible, not for quickly and efficiently making the correct diagnosis.

Early in my career, I was asked to evaluate an elderly woman with shoulder pain. It was of recent onset and without any trauma, and it hurt her to move her arm. I ignored the sweat on her brow and her rapid pulse and high blood pressure and sent her home with instructions for caring for tendinitis of the shoulder. Not long after, an older colleague admitted her to the hospital for a myocardial infarction. My instincts were correct, but my orthopedic exam mislead me.

I vividly remember one day, many years ago, when my wife who is a nurse practitioner called me in to see a young child she was evaluating.

“He just doesn’t look right,” she said.

His vital signs were normal, and his history was benign, but I got the same uneasy feeling.

Moments later, his eyes rolled back, his muscle tone vanished, and he stopped breathing. By that time I already had my arms around his little body and was soon doing infant CPR. My wife and I both knew the child wasn’t right, but neither one of us have been able to describe how we knew.

Would today’s, or tomorrow’s, medical software or artificial intelligence have been able to discern that our young patient was about to slip out of consciousness and why? And if not, how do we ensure that the human beings who practice the art of medicine are allowed and encouraged to cultivate their clinical judgment in this era of standardized and managed care?