Patients with all kinds of symptoms enter through the door of a Primary Care office. Sometimes they don’t know how to describe them or they are afraid to tell them or they go down paths that are far from the real reason behind the appointment. Most of the time, each person comes with more than one problem, and not just clinical ones. From this sea of doubts a decision has to emerge – a change in medication, referral to a specialist or hospital, request for tests… – in a limited time of between five and ten minutes. How long a consultation lasts until the next patient comes in and the clock starts ticking again.
In college and later in residency, future doctors are forced to cram as many clinical guides between their chests and backs; to accumulate all the evidence they can to, from there, make the best decisions. Like a shield against uncertainty. However, there is something much more intangible, despised as “unscientific” by some specialists and barely present in the training that helps in the diagnosis process: hunches.
Intuitive thinking – known as the clinical eye or gut feelingsin English literature – “is another aid in the diagnosis of low prevalence diseases, such as serious diseases in the area of Primary Care,” he says. an article published in the continuing education magazine of the Spanish Society of Family and Community Medicine (Semfyc).
Examples abound in health centers: “That sad and disheveled patient who complained of a stubborn digestive discomfort who ended up being diagnosed with pancreatic cancer; a woman with “reluctance” for whom the administrator was concerned and ended up leaving the center in a mobile intensive surveillance unit (ICU) with a massive heart attack; “the tall boy with fever and sudden fatigue whose mother “didn’t see well” who was referred to the emergency room without a clear diagnosis and was admitted and treated for acute lymphoid leukemia,” includes the investigation led by Dr. Bernardino Oliva, who has a decade studying this little-known side of the profession.
“We get it right 12% of the time”
“The predictive value of hunches is at least comparable to that of many symptoms or signs recognized as alarms. When I entered this world I was surprised to know that it was studied, systematized, that a lot was known about the subject,” says the author in conversation with this medium. The most shocking thing, the family doctor admits, was verifying that “we are right 12% of the time when we have a hunch about a serious illness in the following two months,” according to the results of a study designed in Spain. In the case of warning signs related to some types of cancer, this predictive capacity is usually no more than 5%.
“The finding is interesting and should help us feel more confident when listening to these intuitions, because it moves us to order more tests, spend more time with patients, refer them to other colleagues… In the United Kingdom, for example, They have specific referral circuits for suspected seriousness and one of the criteria they accept is gut feeling from the doctor,” he develops. Intuition works with adults, but also with babies: “The feeling that something was wrong when caring for children with symptoms lasting less than five days, even if there was no data of severity, increased the risk of serious infectious disease. Paying attention to that alarm hunch helped prevent two out of every six serious cases, at the cost of 44 false alarms.”
At the specialized level we already give it much more thought, there is a diagnostic suspicion, but to us the patients come to us blank and hunches are very good for us
Salvador Casado,. family doctor
Salvador Casado has worked as a family doctor for two decades in a health center in the mountains of Madrid. You have ten minutes to see each patient; “luxury in Spain,” he says. “In Primary Care we do not focus on the eye, the ear or the gut. The person can tell you anything, from banal to serious. On that scale, the fear arises of thinking that you are eating with potatoes a cancer that is in front of you and has not shown its face. At the specialized level we already give it much more thought, there is a diagnostic suspicion, but to us the patients come to us blank and hunches help us,” defends the doctor, who regrets that the training of intuitive thinking is not present in the plans. of studies. “It is a very recent line of research to be developed.”
A fresh piece of insider information
The professionals store information on each of the visits. “It’s almost unconscious but it’s in your brain. It helps a lot when you treat them continuously,” according to Hermenegildo Carreras, a family doctor in Zamora and member of Primary Care in the Collegiate Medical Organization (OMC). With successive quotes they paint “an immense fresco, with a multitude of details” about the person: having such extensive knowledge “makes it easier to have hunches of alarm,” says Oliva. It has been proven that having the same family doctor for more than 15 years reduces visits to the emergency room by 30%, hospital admissions by 28% and mortality by 26%, recalled the Secretary of State of the Ministry a few months ago. of Health, Javier Padilla.
“You see a patient you know walk through the door and you know if they are good or bad. You detect if something happens to him”. Pilar Martín-Carrillo, an experienced family doctor who works in Galapagar (Madrid) and is a member of the Amyts union, describes her daily work like this: “The head mentally goes over different paths. With the limited time we have we have to go quickly; now here, now there. Personally, it causes me a lot of stress to think that I’m missing something. So if it’s not clear to me, I ask them to come again.”
That extra time, which is not usual, ended up revealing the situation of gender violence that one of his patients was experiencing. “He came to my office two or three times, he spoke little and his joints hurt. Each time it was a different pain: shoulders, knees, back, chest, stomach, head, he felt sad, he slept badly… I understand that there is something that is causing this condition and I decide to dedicate more time to it – more half an hour of consultation. I ask him about his work and his family. And finally she starts crying and tells me about a lifetime of abuse,” the doctor recalls. The woman was referred to the municipal purple point, received counseling and got divorced.
The patient came to my office two or three times, she spoke little and each time she came with a different pain. I decide to dedicate more time to him – more than half an hour of consultation – and finally he starts to cry and tells me about a lifetime of abuse.
Pilar Martín, family doctor
Although things are not always resolved with such diagnostic success. Martín-Carrillo admits that “the pressure of care, the stress due to the lack of time to let the patient speak and exploit him adequately are very negative factors for detecting or ruling out pathologies and prevent us from thinking with a minimum of peace of mind.” 20 years ago, the doctor treated a “young girl, with a very long and pretty braid” who sat in the office and barely spoke a word. She was depressed, as she admitted to the doctor, who had so many patients waiting that she ended up scheduling her another day because she was aware that she needed more time to speak calmly. “He committed suicide and I was on night duty that day, so we did them. I thought I would die too. “I still feel guilty today.”
“The first years are all sweat, but as time goes by you use everything you can: your experience seeing cases, facing situations, your good and worst decisions…,” Casado acknowledges. These hunches serve to modify on the fly the decision-making system used at all times. They are not diagnostic, but prognostic and dynamic, says the study led by Oliva. All the professionals consulted live with uncertainty and agree that intuitive thinking, that “something is happening here and I don’t really know what”, is a useful tool to challenge it. Or at least try.
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