A Country Doctor Writes:

In 2002, Dr. Trisha Greenhalgh published a piece in the British Journal of General Practice titled Intuition and Evidence – Uneasy Bedfellows? In it she writes eloquently about the things Christer Petersson and I have written articles on and emailed each other about. He mentioned her name and also Italian philosopher Lisa Bortolotti, and I got down to some serious reading. These two remarkable thinkers have described very eloquently how clinical intuition actually works and describe it as an advanced, instantaneous form of pattern recognition.

Clinical Intuition (should we start calling this CI, as opposed to the other, electronic form of pattern recognition, AI – Artificial Intelligence?) begins with clinical patient experience but is cultivated through reflection, writing and dialogue with other physicians. And as Petersson and I have both written, there isn’t enough of the latter in medicine today. Both of us do as much reflecting and writing as we can, but we both know that more collegial interchange can make all of us better clinicians. Greenhalgh writes:

The educational research literature suggests that we can improve our intuitive powers through systematic critical reflection about intuitive judgements–for example, through creative writing and dialogue with professional colleagues. It is time to revive and celebrate clinical storytelling as a method for professional education and development. The stage is surely set for a new, improved–and, indeed, evidence-based–‘Balint’group.
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC1314297/

Bortolotti, the philosopher, makes the case that experts are more intuitive than novices, a skill that only comes with experience, and have developed advanced pattern recognition abilities that allow them to make decisions faster than possible when only using analysis and reasoning. Her article is quote-heavy. She writes:

Dreyfus and Dreyfus develop a different model of the acquisition of expertise in five stages: (1) the novice who relies on surface features of the situation and context-free rules; (2) the advanced beginner who starts perceiving patterns but cannot discriminate between relevant and irrelevant features; (3) the competent decision-maker who can cope with a variety of situations via deliberate planning; (4) the proficient decision-maker who sees situations holistically and arrives at her judgement by exercising her perceptual skills; (5) the expert who has an intuitive understanding of the situation and uses analysis only when problems occur or when the situation is unfamiliar.

She goes on:

Here are some examples of the reaction against the perceived over-conceptualisation of expert decision-making:

The view of expert decision making presented here is perceptual rather than conceptual. It is more a matter of how people see the world than the knowledge that they have accumulated. The reason is that knowledge, to be useful, must be translated into action. From a pragmatic perspective, decision making and problem solving are based on situation awareness, on the recognition of situations as typical or anomalous, and, with that, on the actions that are associated with that recognition. (Hutton and Klein 1999, 32–3)

[W]ith enough experience in a variety of situations, all seen from the same perspective but requiring different tactical decisions, the brain of the expert performer gradually decomposes this class of situations into subclasses, each of which shares the same action. This allows the immediate intuitive situational response that is characteristic of expertise. (Dreyfus 2002, 372).

Expert decision making seems removed from explicit deliberation, unlike novices who rely on explicit instruction when learning a new task. Linked to this, speed of performance increases notably with expertise, whereas novices are slow and deliberate. Experts can multi-task and engage in other activities while making expert decisions, whereas novices can be easily distracted from tasks with which they are unfamiliar. Recognition of visual stimuli and its categorization shifts up a level in speed once one has become expert through repeated experience, allowing experts to respond to and categorize subordinate-level stimuli almost instantaneously. (Nee and Meenaghan 2006, 938)

What is expert decision-making? Hutton and Klein (1999) list the main characteristics: (1) expertise is domain-specific; (2) in comparison with novices, experts do not necessarily have a wider knowledge base, but are better able to perceive patterns; (3) expert performance is faster than that of novices and virtually error-free; (4) experts have superior memory in their domain of expertise, and this is not necessarily all “in their heads” but recalled when needed by means of external cues; (5) experts have a deeper understanding of the problem to solve (e.g. they catch on the causal mechanisms), whereas novices are distracted by superficial features of the problem; (6) experts have a better understanding of their own limitations and an ability to catch themselves when they commit errors; (7) through years of experience, experts acquire the ability to perceive relevant features of the situation (distinguish typical features from exceptions, make fine discriminations, antecedents, and consequences).

In her conclusion, Bortolotti writes that reflection and intuition are both valuable and, when used together (in the right proportions in the right circumstances), make for better decisions.

There seem to be different conceptions of the relationship between reflection and intuition, and they cut across the philosophical and the cognitive science literature:

(1) Pro reflection. Reflection is slower but more accurate, so using intuition instead requires a trade-off: faster and more computationally economic processes in exchange for less accurate decisions. Stop and think!

(2) Pro intuition. Intuition is more accurate than reflection in delivering good decisions, and it is also less vulnerable to evidence manipulation and confabulation. Go with the flow!

(3) Against the dichotomy. Reflection and intuition should not be characterised as dichotomous. Conscious and unconscious, fast and slow, perceptual and analytic reasoning processes interact in the making of good decisions.

Both Art and Science, Medicine encompasses many apparent opposites. The skillful clinician is comfortably considering all of them. Once again I am reminded of how I once thought Dr. Pete, my Residency Director, had a tendency for (as I called it) “shooting from the hip“. What he actually did was practice advanced pattern recognition.