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J Am Coll Cardiol, 2007; 50:1201-1202, doi:10.1016/j.jacc.2007.08.006
(Published online 31 August 2007). © 2007 by the American College of Cardiology Foundation |
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* Address correspondence to: Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92122 (Email: ademaria{at}acc.org).
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The educational aspects of medicine are not the only evidence of deliberate, purposeful, and well-thought-out behavior. Rounds are a classic example of the process of gathering information, discussing options, and planning action. When uncertainty exists, consultations are often called to discuss with and draw upon the experience of those who are more knowledgeable. The epitome of excellent clinical care is said to be the deliberate practice of evidence-based medicine. Our profession seems to be characterized by highly considered cognitive decisions.
I believe there is, however, a very important aspect of medicine that occurs on a subconscious level. For want of a better term, the ability to instantaneously and subconsciously assess the presence, nature, and severity of illness is often referred to as instinct. I have a clear recollection of the moment that this characteristic became clear to me. My internship entailed working every other night and weekend; the year was essentially a blur during which we were either working or sleeping. During the last month I caught sight of a patient being wheeled into the emergency room and instinctively knew he had a gastrointestinal bleed. There followed numerous instances in which I "had a feeling" that someone was well, or ill, or very ill, and often what the cause was, just by seeing them. Similar experiences have occurred with regard to response to therapy, or the lack thereof. In fact, during my 24 years as Division Director I always restricted attending physician duties in the intensive care units to clinically focused faculty who would have the appropriate instincts.
The concept that rapid, primarily subconscious assessment can play an important role in medicine seems at odds with the cerebral nature of the discipline. Therefore, I was pleased to find a book devoted entirely to the existence and importance of these instantaneous appraisals in everyday life. The book, Blink, by Malcolm Gladwell (1), refers to judgments that are made in the blink of an eye. It attributes these actions to the adaptive unconscious, and calls the process thin slicing, that is, the filtering of a massive input to extract the most important factors. Gladwell extols the virtues and accuracy of such assessments, but also cautions how they can lead astray.
The book describes numerous examples of valuable instinctive behavior: the immediate recognition of a fake marble statue alleged to be from 600 BC by antiquarians; a tennis coach who could predict a fault before the ball was hit; students who could rate the ability of teachers within seconds of exposure. Typically, the individuals involved could not articulate what made them reach the judgments they did. Moreover, Gladwell provides evidence that additional time and information can sometimes confuse and obscure correct assessments that were actually made more accurately and quickly with limited data. The old axiom that your first impulse when answering a test question is usually correct may be a manifestation of this concept.
As is often the case, instantaneous subconscious judgments also can convey liabilities. Gladwell’s prototype example of thin slicing gone wrong is deceased President Warren Harding. He was tall, handsome, had a physical grace and a resonant voice; he had the perfect appearance for a president. Unfortunately, he had minimal skills at governing, and is considered one of the least effective men who have held the office. His ability to get elected despite his minimal talents is generally ascribed to the favorable "presidential" impression he made when first seen. Not only can our instincts betray us by mistaking the important features in any situation, but they can be misled by prior exposure. Examples include the association of race with crime and gender with the inability to perform certain activities. These associations were felt to contribute to the mistaken killing of an innocent African American by police and the inability of women to win selection for the horn section of symphony orchestras. It is clear that while instincts are of enormous value, they can also be perverted by bias and lead to erroneous judgments.
As stated at the onset of this essay, in my view instincts play a critically important role in all areas of medicine. One of the most frequent and important settings for cardiologists is in the assessment of chest pain. It is my firm belief that we develop instincts over the years that help us to distinguish those patients with real disease from those without, as well as to estimate the severity of illness. Gladwell offers the evaluation of acute chest pain in the emergency room as an example of intuition leading us astray. However, the regimented approach he presents as superior requires the identification of unstable angina, a task that relies heavily upon clinical savvy. Moreover, he confuses the number of patients needed to treat to obtain a benefit with the accuracy of diagnosis. The evaluation of chest pain can also serve as a prime example of perverted instincts. We are all well aware of the inherent reflex to consider chest pain as noncardiac in females and young men. In aggregate, however, I believe that intuition serves us very well in cardiology in the evaluation of chest pain and in many other clinical settings.
The ability to make accurate instantaneous subconscious assessments is likely the result of both knowledge and experience. Rapidly extracting critically important signals from a huge amount of sensory input represents both science and art. While instinctive judgments are enormously important in every walk of life, they are particularly valuable in medicine. This is especially so in cardiovascular medicine, where rapid decisions in acute settings are frequently required and can be lifesaving. We will always base the practice of medicine upon a cerebral and cognitive platform. However, we will often supplement and sometimes replace these basic principles with subconscious judgments. In my view, we are fortunate to have this option; facility in the application of clinical instincts is likely a major determinant of success in the art of medicine.
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  A. N. DeMaria Tipping Points and Cardiology J. Am. Coll. Cardiol., August 19, 2008; 52(8): 670 - 671. [Full Text] [PDF]
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