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“You see a patient you know coming in and you know if they’re okay or not.”

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Patients with all kinds of symptoms walk through the door of a primary care office. Sometimes they don’t know how to describe them or they are afraid to tell them or they take paths that are far from the real reason for the nomination. Most of the time, every person faces several problems, not just clinical ones. From this sea of ​​doubts, a decision must emerge – change of medication, referral to a specialist or hospital, request for tests, etc. – within a limited time, between five and ten minutes. How long does a consultation last until the next patient arrives and the clock starts ticking again.

In college and later in residency, future doctors are forced to cram as many clinical guides between their chests and backs; to accumulate all possible evidence to, from there, make the best decisions. Like a shield against uncertainty. However, there is something much more intangible, looked down upon as “unscientific” by some specialists and barely present in the training that aids in the diagnostic process: hunches.

Intuitive thinking – known as the clinical eye or instinctive feelingsin English literature – “is another aid in the diagnosis of diseases with low prevalence, such as serious illnesses in the field of primary care”, states an article published in the continuing education journal of the Spanish Society of Family and Community Medicine (.Semfyc).

Examples abound in health centers: “This sad, disheveled patient who complained of persistent digestive discomfort who was eventually diagnosed with pancreatic cancer; a woman “reluctantly” who the administrator became concerned about and ended up leaving the center in a mobile intensive monitoring unit (ICU) with a massive heart attack; “the big boy with fever and sudden fatigue whose mother “did not see well” who was referred to the emergency room without a clear diagnosis and was admitted and treated for acute lymphocytic leukemia”, includes the investigation carried out by the Dr. Bernardino Oliva, who spent a decade studying this little-known aspect of the profession.

“We succeed in 12% of cases”

“The predictive value of intuitions is at least comparable to that of many symptoms or signs recognized as alarms. When I entered this world, I was surprised to know that it was studied, systematized, that a lot of things were known about the subject”, says the author in conversation with this medium. The most shocking, admits the family doctor, was to note that “we are right in 12% of cases when we have a presentiment of a serious illness in the following two months”, according to the results of a study carried out in Spain. warning signs linked to certain types of cancer, this predictive capacity generally does not exceed 5%.

“The result is interesting and should help us feel more confident in listening to these intuitions, because it pushes us to order more tests, to spend more time with patients, to refer them to other colleagues… In the United Kingdom, for example, they have specific reference circuits in case of suspicion of seriousness and one of the criteria they accept is intuition from the doctor,” he explains. Intuition works in adults, but also in babies: “The feeling that something was wrong when caring for children with symptoms lasting less than five days, even in the absence of data on severity, increased the risk of serious infectious disease. Paying attention to this intuition helped prevent two out of six serious cases, at the cost of 44 false alarms.

At the specialized level, we already think about it a lot more, there is a diagnostic suspicion, but for us, patients come to us without answers and the intuitions are very good for us.

Salvador Casado. family doctor

Salvador Casado has worked for twenty years as a family doctor in a health center in the mountains of Madrid. You have ten minutes to see each patient; “luxury in Spain,” he says. “In primary care, we don’t focus on the eyes, ears or intestines. The person can tell you anything, from the mundane to the serious. On this scale, the fear arises of thinking that you are eating with potatoes a cancer that is in front of you and that has not shown its face. At the specialized level, we already think about it a lot more, there is a diagnostic suspicion, but with us, the patients come to us empty and the intuitions help us”, defends the doctor, who regrets that the training in intuitive thinking is not not present in the study plans. “This is a very recent line of research to be developed.”

New privileged information

Professionals store information about each visit. “It’s almost unconscious but it’s in your brain. It helps a lot to treat them continuously,” according to Hermenegildo Carreras, a family doctor in Zamora and primary care member of the Collegiate Medical Organization (OMC). With successive quotes, they paint “an immense fresco, with a multitude of details” on the person: having such in-depth knowledge “makes it easier to have alarming intuitions”, explains Oliva. It is proven that having the same family doctor for more than 15 years reduces emergency room visits by 30%, hospitalizations by 28% and mortality by 26%, the Secretary of State of the ministry recalled a few months ago. . Cheers, Javier Padilla.

“You see a patient you know walk in the door and you know if they’re doing well or not. You detect if something happens to him”. Pilar Martín, an experienced family doctor working in Galapagar (Madrid) and member of the Amyts union, describes her daily work this way: “The head mentally travels different paths. Given the limited time we have, we must move quickly; now here, now there. Personally, it stresses me out a lot to think that I’m missing something. So if it’s not clear to me, I ask them to come back.”

This extra time, which is not usual, ended up revealing the situation of gender violence that one of her patients was experiencing. “He came to my office two or three times, he spoke little and his joints hurt. Each time it was a different pain: shoulders, knees, back, chest, stomach, head, he felt sad, he slept badly… I understand that there is something causing this condition and I decide to dedicate more time to it. – more than half an hour of consultation. I ask him about his work and his family. And finally, she starts to cry and tells me about a lifetime of abuse,” the doctor recalls. The woman was referred to the municipal purple point, received counseling and divorced.

The patient came to my office two or three times, she spoke little and each time she came with a different pain. I decide to spend more time with him – more than half an hour of consultation – and eventually he starts crying and tells me about a lifetime of abuse.

Pilar Martín, family doctor

Although things are not always resolved with such diagnostic success. Martín admits that “the pressure of care, the stress due to the lack of time to let the patient speak and exploit him adequately are very negative factors for detecting or excluding pathologies and prevent us from thinking with a minimum of peace of mind. ‘spirit “. Twenty years ago, the doctor treated a “young girl, with a very long, pretty braid” who sat in his office and barely said a word. She was depressed, as she admitted to the doctor, who had so many patients waiting that she ended up giving him another day because she was aware that she needed more time to talk calmly. “He killed himself and I was on night duty that day, so we did them. I thought I was going to die too. “I still feel guilty today.”

“The first years are a lot of sweat, but over time you use everything you can: your experience in handling cases, experiences in situations, your good and worst decisions…” , recognizes Casado. These intuitions are used to modify on the fly the decision-making system used at any time. They are not diagnostic, but prognostic and dynamic, specifies the study led by Oliva. All the professionals consulted live in uncertainty and agree that intuitive thinking, according to which “there is something happening here and I am not sure what”, is a useful tool to question it. Or at least try.

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