Editorial Journal of the Royal Society of Medicine; 2014, Vol. 107(12) 464–465 DOI: 10.1177/0141076814557302
Is the role of instinct important in medicine? Salil B Patel Peninsula College of Medicine and Dentistry, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK Corresponding author: Salil B Patel. Email: [email protected]
‘I decided that it was not wisdom that enabled poets to write their poetry, but a kind of instinct’, wrote Socrates about this universally animalistic innate behaviour. However, does the instinct shown by artists during the process of creation transcend to the medical realm? Clinicians are practitioners of science, operating as a direct consequence of peer-reviewed data. If this is the case, how can we apply an attribute that does not take into account previous training or education? Instincts must be separated from reflexes, the later being defined as responses to stimuli without conscious thought. On the other hand, Darwin1 defined an instinct as being independent of experience, inherited and hence, unmalleable. Modern neuroscientists, such as Jean-Pierre Changeux, disagree and claim that our instincts are constantly being honed.2 The cerebral cortex is home to millions of uncommitted neurons that fuse when new memories are formed. However, the extent of fusion is not permanent but dependent on subsequent use and resultant reinforcement. If this is true, instinct is not based upon innate behavioural patterns but on previous experiences, which have been reinforced to such an extent that assumptions are made despite a lack of apparent logic. A similar school of thought is that proposed by Donald Hebb in 1949, whereby Hebb claimed that ‘neurons which fire together wire together’.3 Thus, instincts based on previous experiences would have the luxury of already being fused. This ‘Hebbian’ learning would in turn explain the choice of instinctive actions being favoured in high pressure situations. Additionally, multiple activations of neuron pairs would induce synaptic strength, arguably increasing the prevalence of that particular instinct. Atul Gawande, in his book Complications, writes about the role of instinct being essential when, as a surgical resident, he managed to differentiate between cellulitis and necrotising fasciitis.4 He admitted that as the symptoms of both inflammatory conditions looked identical at early stages, his instinct to pick the successful diagnosis ‘was not for logical reasons’. Instincts by definition are not inter-personal and thus, making the conscious decision to act upon or
ignore one’s instinct must be done when taking into account the specific circumstances. No absolute rule can be applied to such unique scenarios. As a surgeon, for example, the decision tends to be more immediate due to the small window of opportunity available when operating. Nurses are asked to check patients’ routine observations at regular intervals. However, should they wake up patients in order to carry out tests? The two schools of thought argue about the benefits of sleep versus the importance of regular quantitative data showing progress (or a lack thereof). David Jones, an acute care nurse, argues that the role of instinct is integral when deciding whether to check often or to delay in favour of respite.5 Instincts are now moving from neuroscience textbooks to courtrooms in our increasingly compensatory culture. Legal cases such as Mueller v. Auker in the US show that instinctive decisions are not discriminated in court.6 In this case, a medical test was undertaken to aid diagnosis of a child. The parents were against the notion of the test and subsequently a detective, stationed at the hospital, temporarily removed the child from their custody. The court ruled that despite the parent’s trepidations, the doctors ‘clinical instinct’ to undertake the test, was of a higher priority due the instinct being a ‘wellrecognized and accepted feature of medical emergency practice’. The judge went on to say that due to the time pressure, the doctor’s decision need not have been a ‘perfect judgment’. Reference was made to Primiano v. Cook, a previous trial whereby similarly, doctoral instinct had been claimed by the defense.7 The judge quoted directly from a medical textbook and stated ‘despite the importance of evidence based medicine, much of medical decisionmaking relies on judgment—a process that is difficult to quantify or even to assess qualitatively’. A 2004 study tested the clinical instincts of staff at two children’s’ intensive care units in Boston, Massachusetts and Zurich, Switzerland.8 Clinicians were asked to predict the likelihood of bacterial infections occurring in each of the 347 patients. Predictions were updated daily until either the
! The Royal Society of Medicine 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Downloaded from jrs.sagepub.com at GEORGIAN COURT UNIV on March 25, 2015
Patel
465
blood culture results had returned or antibiotic therapy was commenced. Retrospective data on the actual presence of infection were collected after the antibiotic therapy had been discontinued. The study showed that the clinicians had a discriminative ability of 0.88 when predicting which children would have a bacterial infection. With 1.00 being perfect discrimination, the clinician’s a priori prognosis based on past experiences and instinctive feelings was incredibly accurate. In another study, spinal surgeons’ instinctive assessments of patients’ psychological states were compared against the recommended Distress Risk Assessment Method (DRAM).9 Eight clinicians (four surgeons and four physiatrists) were asked to categorise 400 patients into the four categories stated in the DRAM questionnaire – normal, at-risk, distressed depressive or distressed somatic. This prospective study found that the group of clinicians were accurate only 44% of the time when using instinct alone. Worryingly, the lead author Daubs said, ‘Physicians did not identify the patients with the most severe level of distress almost 50 percent of the time’. The study also found that experienced clinicians did not perform better than the less experienced. Nietzsche and Tanner write about human traits using the dichotomy of Apollonian and Dionysian philosophies.10 The Apollonian view of reason and logic is balanced by the Dionysian view of emotion and instinct. However, modern neuroscience has proven this simplistic division of human attributes to be false. Instincts can be based upon emotion, reason and logic. With the legal component of medicine becoming ever more important, it is helpful to note that past judicial precedence has come out in favour of clinical instinct. Due to the increasingly clear evidence for an experience-based origin of instinct, its role should not be discriminated against in medicine. The antithesis is also paramount; raising
the role of instinct to that of acting in accordance with evidence is dangerous. A balance is essential. Declarations Competing interests: None declared Funding: None declared Ethical approval: Not applicable Guarantor: SBP Contributorship: Sole author Acknowledgements: None Provenance: Not commissioned; editorial review
References 1. Darwin C. On the Origin of Species, 1st edn. Oxford: Oxford University Press, 1996. 2. Changeux J. The Good, The True, & The Beautiful, 1st edn. New Haven, CT: Yale University Press, 2012. 3. Hebb D. The Organization of Behavior, 1st edn. New York: Wiley, 1949. 4. Gawande A. Complications, 1st edn. New York: Metropolitan Books, 2002. 5. Shepard E. Evidence or instinct? Nursing Times. See http://www.nursingtimes.net/nursing-practice/specialisms/educators/evidence-or-instinct/ 5033789.blog (last checked 27 September 2014). 6. Mueller v. Auker, 576 F.3d 979 – Court of Appeals, 9th Circuit 2008. 7. Primiano v. Cook, 598 F. 3d 558 - Court of Appeals, 9th Circuit 2010. 8. Fischer J, Harbarth S, Agthe A, Benn A, Ringer S, Goldmann D, et al. Quantifying uncertainty: physicians’ estimates of infection in critically ill neonates and children. Clin Infect Dis 2004; 38(10): 1383–1390. 9. Daubs M, Patel A, Willick S, et al. Clinical impression versus standardized questionnaire: the spinal surgeon’s ability to assess psychological distress. J Bone Joint Surg 2010; 18(92): 2878–2883. 10. Nietzsche F and Tanner M. The Birth of Tragedy: Out of the Spirit of Music, 1st edn. London: Penguin, 1993.
Downloaded from jrs.sagepub.com at GEORGIAN COURT UNIV on March 25, 2015
Is the role of instinct important in medicine? Salil B Patel Peninsula College of Medicine and Dentistry, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK Corresponding author: Salil B Patel. Email: [email protected]
‘I decided that it was not wisdom that enabled poets to write their poetry, but a kind of instinct’, wrote Socrates about this universally animalistic innate behaviour. However, does the instinct shown by artists during the process of creation transcend to the medical realm? Clinicians are practitioners of science, operating as a direct consequence of peer-reviewed data. If this is the case, how can we apply an attribute that does not take into account previous training or education? Instincts must be separated from reflexes, the later being defined as responses to stimuli without conscious thought. On the other hand, Darwin1 defined an instinct as being independent of experience, inherited and hence, unmalleable. Modern neuroscientists, such as Jean-Pierre Changeux, disagree and claim that our instincts are constantly being honed.2 The cerebral cortex is home to millions of uncommitted neurons that fuse when new memories are formed. However, the extent of fusion is not permanent but dependent on subsequent use and resultant reinforcement. If this is true, instinct is not based upon innate behavioural patterns but on previous experiences, which have been reinforced to such an extent that assumptions are made despite a lack of apparent logic. A similar school of thought is that proposed by Donald Hebb in 1949, whereby Hebb claimed that ‘neurons which fire together wire together’.3 Thus, instincts based on previous experiences would have the luxury of already being fused. This ‘Hebbian’ learning would in turn explain the choice of instinctive actions being favoured in high pressure situations. Additionally, multiple activations of neuron pairs would induce synaptic strength, arguably increasing the prevalence of that particular instinct. Atul Gawande, in his book Complications, writes about the role of instinct being essential when, as a surgical resident, he managed to differentiate between cellulitis and necrotising fasciitis.4 He admitted that as the symptoms of both inflammatory conditions looked identical at early stages, his instinct to pick the successful diagnosis ‘was not for logical reasons’. Instincts by definition are not inter-personal and thus, making the conscious decision to act upon or
ignore one’s instinct must be done when taking into account the specific circumstances. No absolute rule can be applied to such unique scenarios. As a surgeon, for example, the decision tends to be more immediate due to the small window of opportunity available when operating. Nurses are asked to check patients’ routine observations at regular intervals. However, should they wake up patients in order to carry out tests? The two schools of thought argue about the benefits of sleep versus the importance of regular quantitative data showing progress (or a lack thereof). David Jones, an acute care nurse, argues that the role of instinct is integral when deciding whether to check often or to delay in favour of respite.5 Instincts are now moving from neuroscience textbooks to courtrooms in our increasingly compensatory culture. Legal cases such as Mueller v. Auker in the US show that instinctive decisions are not discriminated in court.6 In this case, a medical test was undertaken to aid diagnosis of a child. The parents were against the notion of the test and subsequently a detective, stationed at the hospital, temporarily removed the child from their custody. The court ruled that despite the parent’s trepidations, the doctors ‘clinical instinct’ to undertake the test, was of a higher priority due the instinct being a ‘wellrecognized and accepted feature of medical emergency practice’. The judge went on to say that due to the time pressure, the doctor’s decision need not have been a ‘perfect judgment’. Reference was made to Primiano v. Cook, a previous trial whereby similarly, doctoral instinct had been claimed by the defense.7 The judge quoted directly from a medical textbook and stated ‘despite the importance of evidence based medicine, much of medical decisionmaking relies on judgment—a process that is difficult to quantify or even to assess qualitatively’. A 2004 study tested the clinical instincts of staff at two children’s’ intensive care units in Boston, Massachusetts and Zurich, Switzerland.8 Clinicians were asked to predict the likelihood of bacterial infections occurring in each of the 347 patients. Predictions were updated daily until either the
! The Royal Society of Medicine 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Downloaded from jrs.sagepub.com at GEORGIAN COURT UNIV on March 25, 2015
Patel
465
blood culture results had returned or antibiotic therapy was commenced. Retrospective data on the actual presence of infection were collected after the antibiotic therapy had been discontinued. The study showed that the clinicians had a discriminative ability of 0.88 when predicting which children would have a bacterial infection. With 1.00 being perfect discrimination, the clinician’s a priori prognosis based on past experiences and instinctive feelings was incredibly accurate. In another study, spinal surgeons’ instinctive assessments of patients’ psychological states were compared against the recommended Distress Risk Assessment Method (DRAM).9 Eight clinicians (four surgeons and four physiatrists) were asked to categorise 400 patients into the four categories stated in the DRAM questionnaire – normal, at-risk, distressed depressive or distressed somatic. This prospective study found that the group of clinicians were accurate only 44% of the time when using instinct alone. Worryingly, the lead author Daubs said, ‘Physicians did not identify the patients with the most severe level of distress almost 50 percent of the time’. The study also found that experienced clinicians did not perform better than the less experienced. Nietzsche and Tanner write about human traits using the dichotomy of Apollonian and Dionysian philosophies.10 The Apollonian view of reason and logic is balanced by the Dionysian view of emotion and instinct. However, modern neuroscience has proven this simplistic division of human attributes to be false. Instincts can be based upon emotion, reason and logic. With the legal component of medicine becoming ever more important, it is helpful to note that past judicial precedence has come out in favour of clinical instinct. Due to the increasingly clear evidence for an experience-based origin of instinct, its role should not be discriminated against in medicine. The antithesis is also paramount; raising
the role of instinct to that of acting in accordance with evidence is dangerous. A balance is essential. Declarations Competing interests: None declared Funding: None declared Ethical approval: Not applicable Guarantor: SBP Contributorship: Sole author Acknowledgements: None Provenance: Not commissioned; editorial review
References 1. Darwin C. On the Origin of Species, 1st edn. Oxford: Oxford University Press, 1996. 2. Changeux J. The Good, The True, & The Beautiful, 1st edn. New Haven, CT: Yale University Press, 2012. 3. Hebb D. The Organization of Behavior, 1st edn. New York: Wiley, 1949. 4. Gawande A. Complications, 1st edn. New York: Metropolitan Books, 2002. 5. Shepard E. Evidence or instinct? Nursing Times. See http://www.nursingtimes.net/nursing-practice/specialisms/educators/evidence-or-instinct/ 5033789.blog (last checked 27 September 2014). 6. Mueller v. Auker, 576 F.3d 979 – Court of Appeals, 9th Circuit 2008. 7. Primiano v. Cook, 598 F. 3d 558 - Court of Appeals, 9th Circuit 2010. 8. Fischer J, Harbarth S, Agthe A, Benn A, Ringer S, Goldmann D, et al. Quantifying uncertainty: physicians’ estimates of infection in critically ill neonates and children. Clin Infect Dis 2004; 38(10): 1383–1390. 9. Daubs M, Patel A, Willick S, et al. Clinical impression versus standardized questionnaire: the spinal surgeon’s ability to assess psychological distress. J Bone Joint Surg 2010; 18(92): 2878–2883. 10. Nietzsche F and Tanner M. The Birth of Tragedy: Out of the Spirit of Music, 1st edn. London: Penguin, 1993.
Downloaded from jrs.sagepub.com at GEORGIAN COURT UNIV on March 25, 2015
