Gut Feeling #illumedati


Hey everyone, it’s Medicine Mondays again. Today I’m going to talk about something that is kind of difficult to explain, but is best summed up as “Gut Feeling“.

Gut Feeling

Stock Photo from: Pixabay

What do you mean “Gut Feeling”?

Well, the idea of a gut feeling is kind of a general one. I’ve talked about it before when it comes to choosing a residency. However, in today’s post we’re talking about the gut feeling in regards to being in the medical field, specifically as a doctor.

I’ve talked before that “Experience Matters“. I think it is underestimated in our profession. The Dunning-Kruger effect occurs for all of us, to a certain extent. You don’t know what you don’t know and all of that. Experience is not a substitute for knowledge. However, knowledge is also not a substitute for experience. You need both.

Once you have both, then you develop a “Gut Feeling”. It’s the feeling that there is something not quite right here, but you can’t necessarily explain it. This event comes from having both knowledge and experience. Your knowledge tells you it most likely one thing, but your experience holds you back from locking it in.

Hmm… do you have an example?

Sure.

I’m a neuroradiologist, so I read a lot of head CTs… like a lot.

For the most part, you see a lot of white matter disease which is almost always chronic microvascular ischemic change. However, I had a case the other day where something was just a little bit off. The degree of white matter disease was just a little too much to simply be chronic microvascular ischemia. Additionally, the area that was affected didn’t seem to have volume loss (encephalomalacia) from a prior insult like prior stroke. It was subtle, but it made me pause. However, in general, if you’re going by the numbers this would still probably be chronic microvascular ischemia 99 times out of 100.

However, my gut feeling told me to do a little more digging. I looked back at his recent studies and on his chest x-ray there were multiple pulmonary nodules, which of course, is metastatic disease until proven otherwise. This changes things now. The overall picture has changed. While this could still be chronic microvascular ischemia, it was just atypical enough and just not “normal” enough to go above my threshold to question brain metastases. I called the referring physician, discussed the findings and said while it could be just atypical chronic microvascular ischemia, I was worried enough to recommend a brain MRI with and without intravenous contrast. The referring physician thanked me for the call and my concern and said they’d get a follow-up brain MRI.

So what happened?

Now, I didn’t read the follow-up brain MRI because it wasn’t performed during my shift. However, the guy who did read it sent it to me for follow-up. So what did he see?

Brain metastases — like everywhere. Both cerebral and cerebellar hemispheres were involved. The largest one was in the area I questioned, but the others were completely occult on the noncontrast head CT. Why does this matter? It changes management. If there were no brain metastases, the therapeutic options change. If there is a single solitary brain metastasis, therapeutic options change. However, with multiple bilateral lung and brain metastases, the case can be made for palliative care, depending on the primary.

Nice call.

My colleague commented that it was a great call and that he thought few others would have been able to call it prospectively. However, please don’t misunderstand the point of this post. I’m not bringing this up to beat my chest and declare that I’m a great radiologist or anything like that. I’m just a regular guy trying to do a good job, and I try to stay cognizant of my own weaknesses and faults.

The reason I’m bringing this up is because sometimes you have these gut feelings. Don’t ignore them. These gut feelings are your experience telling you to look deeper, investigate further… something isn’t quite right here.

I’m also bringing this up because I don’t think I would have had the same response as a young attending. You develop this gut feeling from your built-up experience. I simply did not have the experience built up yet for this “gut feeling” to kick in. Me as a young attending out of fellowship probably would have dismissed this finding as somewhat atypical white matter disease, because, in general, that’s what it will be 99 times out of 100.


Any other examples?

Well, let’s talk about my wife’s “gut feeling”. She’s both an adult psychiatrist and child & adolescent psychiatrist. She’ll never tell you, but she’s pretty amazing at what she does. Anyone who knows her will comment that she’s probably one of the best psychiatrists around. Of course, she doesn’t think she’s all that special — but I assure you she is.

If there is any better specialty to trust your “gut feeling”, it’s psychiatry. As a psychiatrist you are relying on both the objective and subjective information that you gather. You have to pay attention to not just what your patient says, but how they say it, and whether they’re hiding something or minimizing it. You need to be very sensitive to all these little cues in order to not miss anything. More so than that, you must recognize this cues and be able to ask the right follow-up questions to gather the additional information you need. Additionally, try to imagine getting this information in a short time frame and establish enough rapport with your patient that they trust you.

I’m sure that these kind of gut feelings happen to my wife on a daily basis. Like I said above, a lot of this comes from experience.


Can medical students have a gut feeling?

Sure.

Experience isn’t necessarily based on time, it’s based on events. It doesn’t necessarily matter how long you’ve been in the medical field, you will get these gut feelings from time to time. The difference is that you gain the ability to trust them.

For example, let’s say you’re a 3rd year medical student on the east coast and you’re in the final weeks of your infectious disease rotation. A patient comes in presenting with weird symptoms and everyone thinks this person has tuberculosis. They put him on airborne precautions, send out cultures, and start the antibiotics empirically. However, cultures and results can take awhile to come back and the patient isn’t doing any better. No one has any idea what is going on.

However, you’re originally from Bakersfield, in the heart of Central California. You remember as a kid that people always had this thing called Valley Fever, which can mimic TB. Has anyone asked where this guy is from, you wonder?

During morning rounds, you ask the attending on rounds… where is Mr. Smith from? Oh, he’s from out in Delano in Central California. He was just out here visiting his daughter and suddenly felt sick. “Could it be Cocci?” you ask. Suddenly everyone one rounds is abuzz… could it be Cocci? Maybe. New cultures are sent out. A more in depth history is obtained. Antibiotics are re-evaluated.

Results later confirm that the patient has Coccidioidomycosis.

Only your knowledgeexperience, and gut feeling of “could it be?” would make you consider the possibility of Coccidioidomycosis in a patient on the East Coast.


Anything else?

Yeah.

I think being aware of your “gut feeling” is a good idea. It stems from experience built on knowledge. However, I don’t think we should just jump to act on our gut feelings.

“Trust, but verify.”

Trust that your gut feeling is correct, but don’t just jump to act on it. Verify and confirm why you have the gut feeling that you do. Your gut feeling can still be wrong.


TL;DR

A “gut feeling” comes from knowledge and experience. Don’t just dismiss it.

That said, don’t just jump to act on a gut feeling either.

Trust, but verify. Your gut feeling can still be wrong.

 

Medicine Mondays Sensei

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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