Wednesday, June 17, 2009

Intuition in Psychiatric Practice

Another question from a visitor:

Evidence-Based Medicine: Do you find that intuition has its place in practice of clinical psychiatry? Despite years of positive experience with a certain technique or medicine, would you decide against it if the only study done on it finds it harmful or useless? If not, how do you go about qualifying your sense of intuition and personal experience?

Good question. I think the crucial point here is "what constitutes evidence?"

Years of positive personal experience with something is itself a strong type of evidence. A negative study is another type of evidence. In all logical assessments of treatments, we must weigh the positive evidence against the negative.

If there was such a strong negative study, particularly if it was done with scientific and statistical rigour, it should lead to a critical re-appraisal of one's own practice, to examine reasons why one's own experience was so different from what another study shows. We should always be prepared to change our ways if strong evidence challenges the status quo.

I don't think "intuition" need be placed in opposition to "logic" or "evidence." I like to think that healthy intuition is a way to incorporate logic and evidence in a way which is flexible and open-minded, and which allows room for creativity.

In clinical practice, a manifestation of "intuition" may at times be a product of a great deal of experience or mastery in something (with the acquisition of "formal operations" in one's area of specialty, in a Piagetian sense), such that pattern recognition and responses can happen very quickly. We can see this in chess players, musicians, auto mechanics...any type of acquired expertise. Things appear to happen effortlessly, seemingly without a thought--certainly without the laborious calculations or stilted rumination which a beginner might apply to the task. These "formal operations" though, represent a great efficiency of weighing evidence and decision-making, not an absence of reason. Those who reject formal evidence in favour of their supposed "intuition" are in a different camp. This would be like the chess player or musician who does not pay attention to his or her weaknesses of technique, or like the auto mechanic who doesn't bother to check the oil. I consider this practice to be inefficient and potentially quite dangerous. There are studies which show that "intuitive" diagnostic impressions in psychiatry are often inaccurate (I'll have to find some references); yet I return to my claim that intuition can be a manifestation of our ability to process information quickly, efficiently, even subconsciously, and often with a natural grace and ease which can be a joy of life to practice or witness.

But intuition cannot be used recklessly or with disregard for other types of evidence.

Conversely, over-reliance on non-intuitive evidence can also be stilted and inefficient. The musician who has note-perfect technique, without grace, is uninteresting. A physician who goes through a symptom checklist meticulously, but fails to attend to alarming non-verbal cues, may entirely miss the underlying problem--a problem which is not detectable by a checklist, because checklist data may not be valid or relevant in cases where process is not attended to.


Anonymous said...

Thank you for making clear your view, Dr. Kroeker.

I once had a conversation with a hardcore proponent of evidence-based medicine, a certain professor. It was an impossible debate--most dogmatic. Yet I could not mount a convincing rebuttal to his arguments.

Even when the most self-evident matter was discussed, he would criticize my intuitive response, saying forcefully "How do you know?!"

Only when there was absolutely no research available, would he permit intuitive solutions.

However, when any research study of any quality were available, it would be deemed superior to a resolution that would be based on experience.

For instance, let us assume the only blind experiment conducted was done on, say, patients with GAD. He would say that we have to use the results for patients with OCD also. Same thing, if the patients with GAD had any number of comorbidities.

How were we to trust our intuition?

He would cite studies that convincingly showed one's intuition was not to be trusted. I wonder if you have had to argue such points in your career.

GK said...

Thanks for the comment. I've responded to it by adding to my original post.

p.s. I'm preferring to limit personal identifying information for most comments. I also may not publish every comment -- I've had a lot of comments & requests for posts on various things, and I may not have the time or energy to respond to every one. I enjoy writing but my motivation to write comes in erratic spurts.