Elephants, bushes, hot porridge… and clinical intuition?

KEYWORDS:

• Intuition
• medical judgment
• phenomenology
• clinical reasoning
• Praecox Gefühl

There is a Scandinavian expression, to pace around hot porridge like a cat. It means avoiding a complicated topic, and corresponds to sayings such as beating around the bush and ignoring the elephant in the room. This idiom might be reformulated, when it comes to training of doctors, as to pace around clinical judgement like a medical educator. When questions about judgement arise, intuition is more easily summarised as experience assimilated by senior colleagues, than elaborated on with regards to an actual epistemological meaning. This provides a false sense of security: riding roughshod over the implicit component of clinical judgement paves the way for irrational solutions to conflicts among physicians, replacing closer examinations of individual patients by decisions based on routine or charisma alone.

An essentially intuitive work for psychiatrists is exploring psychosocial and existential domains of the patient’s illness, and personally connecting with the individual patient – this cannot be captured in an algorithmic flowchart [1]. But just like a picture says more than a thousand words, intuition has been difficult to discursively pin down. The Evidence-based Medicine (EBM) movement jettisoned the tacit aspects of clinical reasoning present in its precursor discipline (‘Clinical Epidemiology’) [2]. In our experience, clinical intuition in psychiatry is a two-way process over time, between clinician and patient, depending in part on the verbal and non-verbal dialogue with the patient – reflecting issues such as the patient’s values, norms and idiosyncratic assumptions about self and the world – and in part in the internal dialogue of the clinician, conscious and reflective as well as prereflective.

But how can we describe clinical intuition as something other than argument from authority? In Lund 1892, intuition (comprehensio aesthetica) was elegantly defined as the opposite of discursivity or stepwise analysis (comprehensio logica), the latter which it paradoxically incorporated: intuition was a rapid form of logical discursivity, in which the familiarity of the content allowed it to be retained in memory and conscious perspective, thereby (metaphorically) observed rather than deduced. According to this theory, intuition’s emotional nature is a response to a coherent, synthesised whole rather than fragmented, analysed parts, and is therefore more rational than impulsivity. Although fallible (just like deductive reasoning is fallible), intuition is not necessarily irrational, and informs, rather than dismisses, arguments [3]. Following this theory in the clinical setting, intuition actualises and integrates uncountable diverse conceptions from medical knowledge in a humanistic synthesis particular to each patient, emanating with incalculable ramifications from insights into the human condition. Intuition contributes with a wider sense of the patient as a whole, which provides substrate for judicious emotional awareness; the signature feature of intuition. Analytic reasoning cannot access at the same time, let’s say, last week’s conference on population-level data, intra-personal data from previous conversations on the ward, and the clinician’s own embodied knowing of what it means to be human. Psychiatric disorders exist in whole contexts, and the variables to be targeted in clinical measurements are best decided by clinicians familiar with the whole of their practice, rather than originating in abstract models, sometimes pertaining to disciplines unfamiliar with the clinical context. Hence, the distinction between clinimetrics and psychometrics, with the former drawing more on the qualitative basis in the dissected intuition of proficient doctors, and the latter drawing more from multivariate methods in statistics [4].

By assessing the patient as a whole, clinical intuition provides the holistic data necessary for generating humanistic hypotheses about the patient’s condition. Since every patient is unique in regards to personality, biological variation and environmental exposure, the most appropriate way to conceptualise treatment is as an experimental act, which needs to be designed and evaluated for each individual patient, with the evidence as control to be replicated [5]. Whenever a psychiatrist treats a patient, if scientifically and ethically sound, a qualitative piece of experimental field work in psychiatric research is performed, that aims to reproduce previous successes in therapy. Accentuating that each treatment is wrapped in experimental uncertainty is arguably a favour for patient autonomy.

With this idea of clinical psychiatry as a truly humanistic basic research science, we seek to unyoke intuition from the unspoken truths of elephants, bushes, and hot porridge. Not only gestalt judgments themselves, but how they are formed, will be a matter of interest. We wish to explore the role of intuition in inductive, deductive, and abductive reasoning, and in relation to the field of psychopathology. Naturally, intuitionism in clinical ethics will also be reexamined. Assured that intuition is an inalienable cognitive feature of human thinking, that nevertheless can be consciously dissected into discrete elements, we seek to develop guidelines for solving conflicts between divergent intuitions, telling the mature intuition from the naive, and using tools from phenomenology to scrutinise intuitive inferences and affective clues in clinical judgement [6]. An epistemological validation of the arcane Praecox Gefühl, an intuition arising when diagnosing schizophrenia, might be found by conducting phenomenologically oriented interviews with clinicians, and correlating these interviews with the present intuition-as-synthesis theoretical framework. If successful, our approach could potentially help balance the purely analytic criteria found in the DSM [7].

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

M. Lindén

M. Lindén is a medical student at Lund University, affiliated with History of Medicine at Lund University, with an avid interest in philosophy of science.

H. D. Braude

H. D. Braude, MBBCh PhD is an integrative medicine doctor, neuro-ethicist and expert in philosophy of medicine; director-founder of the SomaticWell Center; author of numerous publications in the fields of philosophy of medicine and neuroethics, including Intuition in Medicine: A Philosophical Defense of Clinical Reasoning (The University of Chicago Press, 2012).

J. Herlofson

J. Herlofson, MD is a Swedish psychiatrist, writer, and psychotherapist; Editor and co-author of the most comprehensive Swedish textbook of psychiatry; expertise includes clinical diagnostics with special focus on the value of integrating the diagnostic dialogue as a component of the treatment process in psychotherapy and general clinical psychiatric care.

J. Nordgaard

J. Nordgaard, DMsci, PhD and MD is Associate Professor at the University of Copenhagen, Senior Consultant at Mental Health Services, Capital Region, Denmark; President of the European Association of Phenomenology and Psychopathology; Chair for Institute of Psychopathology; On the Editorial Board of Psychopathology; authored numerous peer-reviewed journal articles.

R. E. Kelly

R. E. Kelly, Jr., MD is an American psychiatrist with additional expertise in mood disorders, neuroimaging and research methods; completed medical school at Lund University 1996; joined Weill Cornell Medical College 2010 and Lund University 2022; Associate Editor for Nordic Journal of Psychiatry; Editor for the Psychiatric Diseases Section of Brain Sciences.

J. Eberhard

J. Eberhard, MD, PhD is a Swedish psychiatrist, Associate Professor at Lund University, Clinical Sciences, Helsingborg, where he is Consultant and Project Manager for Severe Mental Illness Research Unit; Vice Chair for the Swedish Psychiatric Association; authored numerous published articles related to psychiatry; Associate Editor for Nordic Journal of Psychiatry.