To Understand What You Already Know

I read an article last weekend in Allmän Medicin by my Swedish colleague, Christer Petersson, who once wrote a piece titled “I worked as a doctor for 20 years. Then I became one”.

He again writes about the difference between academic knowledge and experience-based intuition and how each is necessary to acquire and cultivate in order to be a good physician. He draws from Russian author Mikhail Bulgakov and American Nobel Prize winner Daniel Kahneman (I now have both books).

In A Young Doctor’s Notebook, Bulgakov describes how his obstetrics textbook made no sense to him until he, with the help of a seasoned midwife, performed a version of a transverse fetus in the middle of the night. After that, he returned to his textbook and wrote:

It was just after one o’clock when I got home. In a patch of lamplight on the desk in the study Döderlein lay peacefully open at the page ‘The Dangers of Version’. I sat with it for another hour or so, gulping tea that had grown cold, leafing through its pages. And now something interesting happened: all of the formerly obscure bits became completely comprehensible, as though they had filled with light, and there, in the light of the lamp, at night, in the back of beyond, I realized what real knowledge means. “There’s great experience to be gained in the countryside,” I thought, falling asleep, “only I have to read, read a lot… read…”

Kahneman, an economist, writes in Thinking, Fast and Slow about the value of clinical intuition, and explains it as a result of learning:

We have all heard such stories of expert intuition: the chess master who walks past a street game and announces “White mates in three” without stopping, or the physician who makes a complex diagnosis after a single glance at a patient. Expert intuition strikes us as magical, but it is not. Indeed, each of us performs feats of intuitive expertise many times each day. Most of us are pitch-perfect in detecting anger in the first word of a telephone call, recognize as we enter a room that we were the subject of the conversation, and quickly react to subtle signs that the driver of the car in the next lane is dangerous.

The psychology of accurate intuition involves no magic. Perhaps the best short statement of it is by the great Herbert Simon, who studied chess masters and showed that after thousands of hours of practice they come to see the pieces on the board differently from the rest of us. You can feel Simon’s impatience with the mythologizing of expert intuition when he writes: “The situation has provided a cue; this cue has given the expert access to information stored in memory, and the information provides the answer. Intuition is nothing more and nothing less than recognition.”

Petersson Writes:

As family physicians we are next-door neighbors to uncertainty. Not infrequently do we have to make decisions without suspenders or a belt (Swedish expression for leaving your comfort zone). Our judgment is constantly being tested. Without intuitive sensitivity we become paralyzed and without analysis we become reckless. Only in our encounters with individual patients’ concrete problems and by connecting those to our profession’s collective knowledge, textbooks and databases can our judgment evolve.

For the general practitioner it is primarily the patient encounter that creates experience. Communication between colleagues, one on one or in a group setting, is in my opinion a necessary ingredient for growing that knowledge.

He writes that there is much to be done with that in Sweden. Here, too, is what I think. Professional isolation in American primary care is possibly worse. And primary care providers are often thought of as interchangeable. Experience and intuition are not valued the way they might be in other fields or in other practice settings, like academic medicine.

Editor’s (that’s me) note:

I sent Christer my draft for this post and he gave me some names, and synopses of writings by people who have written eloquently about intuition. I will be doing some more reading and thinking. Stay tuned for another post about the science behind clinical intuition.

6 Responses to “To Understand What You Already Know”

  1. 1 N. Hoffman July 4, 2021 at 5:41 am

    Thank you so much for doing these posts. They are a breath of fresh air!

  2. 2 Lisa Scheid Ramey MD July 4, 2021 at 5:57 am

    Love this! I repeatedly wished that I could take the Biology of Disease course from second year medical school, again, after having seen a few years of patient care. My patients have taught me so much, and my love of reading also. Thanks for this insight!

  3. 3 David Welsh July 4, 2021 at 8:53 am

    Thanks. That is so true! After 30 years, it is just pattern recognition. I find therapeutic trials and reviews very useful as well…..

  4. 4 G.B. July 4, 2021 at 10:01 am

    Thank you! It is so true.

    After many years GP practice i feel more safe with my decisions and care. But it is a profession to be alert every minute because circumstances and persons are never the same.

  5. 5 dianehaugen July 4, 2021 at 8:05 pm

    Just wanted to tell you how much I enjoyed your post on intuition.

    Primary care physicians and the knowledge they bring to the care of their patients is so undervalued in the U.S. culture. The American public has been schooled to think only something loudly labeled expert is of any value, which only corrupts our healthcare system even more along with the politics and corporate greed.

    I’d really like to see a web site devoted to the art brought to medicine by primary care physicians. The Direct Primary Care movement has done a lot to bring some attention to the value of primary care, but the public needs to learn the root of real expertise, and hence, what you call intuition or sometimes the art of medicine.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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