When I say … intuition

Abstract

Since Greek philosophers debated meaning and reason, humanity has wrestled with the definition of intuition and its value in addressing fundamental questions. In recent decades, social sciences have expanded our understanding of what Chudnoff describes as ‘a form of intellectual perception’.¹ In the 1970s, researchers and educators began to take a genuine interest in intuition within medicine.² Since then, a wealth of research has enriched our comprehension of the role of this process in decision-making. The concept, however, remains clouded by misconceptions. In this When I Say … article, we challenge some widespread beliefs among educators and clinicians to reshape their perspective on intuition and its development among medical students. We primarily focus on intuition in diagnostic reasoning for clarity of argument.

A first misconception is that intuition is the attribute of experts. Yet, if we think of intuition as a skill, the most novice of novices is just as intuitive as the most expert of experts. All of us process information very economically in terms of cognitive resources, forming an idea of what is happening almost instantaneously³ and acting accordingly, thanks to the recognition of similarities with previous exposures. The difference lies not in the process but in its outcome: in their domain, experts' intuitions are sharper, more specific and more accurate than those of novices.⁴ Where a novice might sense that someone is simply ‘sick’ or suspect a vague ‘heart problem’, the expert will recognize a probable case of myocardial infarction. The essence of expertise does not reside in any general problem-solving skills but in the knowledge developed and organized around specific representations of clinical problems. Consider the analogy of an engine. The engine (intuition) is actively at play for novices and experts alike. The key distinction lies in the availability of fuel to power it, i.e. the quantity and quality of knowledge, its organization in long-term memory, and the density of the network interweaving it in the form of instances, prototypes and scripts.⁴ The efficacy of intuition, thus, cannot be disentangled from the context within which it unfolds—embodied by the environment, the task at hand and the objectives pursued by the individual, in relation with their role and responsibilities—highlighting the idiosyncratic nature of expertise.⁵ In the realm of medical practice, this suggests that novices, in contrast to experts, possess a less refined professional intuition, shaped by experiences that are still in the process of being honed.

Therefore, intuition is present in all of us; its effectiveness is sculpted by the quality of knowledge and experience informing it, alongside the specific context in which it operates.

Another widespread belief, appealing in its semblance of rationality, casts intuition as the primary source of diagnostic errors.⁶ Yet intuition acts as the compass that steers the diagnostic process on its path, serving as the cornerstone of expert performance.⁴ Consider a case of chest pain. In a fraction of a second, experts' intuition sweeps aside hundreds of improbable causes, retaining just a few: those that resonate in the context. Human working memory is minimal. Burdening it with countless hypotheses leads to cognitive overload, which impairs diagnostic performance. The same is true when reasoning inductively: collecting data without a guiding framework is like assembling a jigsaw puzzle with no picture to follow. The result may be a scatter of disjointed pieces with no certainty that all the pieces belong to the same puzzle. To be effective, the human brain has no choice but to start at the end—the diagnosis and differential diagnoses, referred to in their early form as hypotheses—and work economically towards the denouement (the prioritization of the hypotheses, and their confirmation or refutation). This approach is not merely efficient; it is essential to human survival. Our brain diagnoses relentlessly, identifying a familiar face in a crowd, recognizing an object at a glance, or sensing a situation that echoes in our memory. Every day, we perform hundreds of silent diagnoses. Life would not be ours if we had to think every time we recognized. Intuition is not simply how we reason—it is how we exist. Certainly, this does not signify that intuition is infallible. Yet, attempting to silence its murmur or curb its flow would invariably prove counter-productive, even for novices.^{4, 7}

Therefore, intuition is not something to restrain but to embrace.

A third widespread belief suggests that experts possess the ability to select their cognitive processes based on the complexity of the problem at hand, deliberately tempering or inhibiting intuition in favour of reflection.⁸ This postulate, alluring in its promise of a ‘supracognitive intelligence’, sometimes called ‘metacognition’, capable of transcending the mind's natural tendencies, comes up against an implacable reality: intuition asserts itself as an unyielding whisper of the mind, i.e. our ‘default way of thinking’ that is irrepressibly triggered.⁹ It serves not merely as the first light illuminating the contours of a situation, but it persists as a constant presence throughout the journey—a compelling force beyond the clinician's capacity to exclude from the decision-making process. Faced with the intricacies of a complex case, analytical reasoning assumes a crucial role in the symphony of thought. Yet reflection must not seek to dismiss the insights sparked by intuition. Rather, analytical reasoning should weave itself seamlessly into the tapestry of those initial impressions, honing and expanding their scope.

Therefore, neither intuition nor analysis stands alone; it is their interplay that illuminates the path to understanding challenging cases.

Deconstructing preconceived ideas about the functioning of intuition is an educational imperative. Health professionals in training should be guided to cultivate a fine, nuanced understanding of intuition, not as a privilege of experts or a pitfall to avoid, but as a paramount resource firmly rooted in their daily lives. Intuition will become increasingly effective to solve patients' health problems as students' clinical exposure grows. These experiences occur when students are required to solve a patient's health problem, whether embodied in written case studies (in a classroom), simulations (during practical sessions) or interactions with real patients (on clinical placements). Each of these serves as a valuable opportunity for developing intuition, provided they are coupled with timely, relevant and unambiguous feedback.^{4, 9}

By supporting clinicians to trust their intuition and facilitate its development, the decision-making process is enhanced, and patient care is improved.

Thierry Pelaccia: Conceptualization; writing – original draft. Jonathan Sherbino: Conceptualization; writing – review and editing. Peter Wyer: Conceptualization; writing – review and editing. Geoff Norman: Conceptualization; writing – review and editing.