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The risks of the dominance of evidence based practice

A scientific study this week has been published suggesting that doctors need to trust their ‘gut feelings’ and intuitions for the sake of their patients. This study [1], published in the British Medical Journal,   looked at  the cases of nearly 4,000 children, and found that a doctor’s intuitive feeling that something is not right, even when a formal examination has found nothing wrong,  can have greater diagnostic value than relying on most symptoms and signs, when trying to spot certain illnesses.  In these cases, the probability of a serious infection decreased from 0.2 percent to 0.1 percent when gut feeling was absent. It is not always possible to work out what signals are being picked up which give rise to the alarm bells ringing, sometimes this comes from the way parents talk about the issues, sometimes from other signs. The researchers go as far as recommending that medical schools should make it clear that an “inexplicable gut feeling is an important diagnostic sign’. This is one of a number of studies which have been questioning the principles of Evidence Based Practice (EBP), and indeed another was published online this week that challenges the very epistemological foundations of EBP [2].

 

The question of when to rely on gut feelings as opposed to protocols and following procedures is an important one in today’s public sector, but one which gets little air space. As Trisha Greenhalgh has long argued [3],  the ideological battle seems to have been won by evidence based practice and it is hard to argue against it, yet very often it’s assumptions are not sufficient for good practice out in the clinical field.  In her writing she has often reported cases of intuitive responses by doctors that have been life-saving, clinical hunches that have prevented medical disasters or picked up suicidal risk for which there might be no overt sign. At one level, this is a classic example of the differences between how the right and left hemispheres of our brains work, as Iain McGIlchrist has so eloquently illustrated [4]. He and many others have pleaded for a more balanced relationship between right hemisphere intuitive forms of knowing and left hemisphere, more deductive kinds. He has argued forcefully that  over-confidence, certainty and the refusal to countenance competing ideas is typical of left hemisphere dominance, seen often in those with right hemisphere strokes, and increasingly seen in many aspects of our society in which the left hemisphere, he argues, is becoming dangerously powerful. Greenhalgh suggests that there is no substitute for clinical experience, and that diagnoses and making sense of people’s presentations can often happen in an intuitive flash.

We might think also of the neuroscience research such as that of Antonio Damasio.  In his famous Iowa gambling task [5], people are presented with four decks of cards. Some decks yield huge winnings but also big losses, others do not perform so spectacularly but eventually pay out profitably. Participants seem to learn non-consciously and intuitively whether a deck of cards is trustworthy or not, something that they could not work out logically. The physiological signs of this are seen for example in sweaty palms and shallow breathing, bodily intuition being well ahead of the rational mind.  Patients with damage to their ventromedial prefrontral cortex did not read such signs, going after the immediate big rewards and not able to resist temptation.  We need to be able to trust such physiological signs, or at least take them seriously, and that is something that it is getting harder and harder to do in mental health services geared to EBP, rigidly defined protocols, and increasingly being delivered by less experienced clinicians trained to deliver manualised treatments by the book. This of course is not to idealise intuition. It is often wrong, as much of the research shows [6], and many of our cherished certainties can rightly be challenged by alternative and well put together evidence. However in today’s NHS, and increasingly in mental health delivery, there is less and less room for relying on what the psychoanalyst Wilfred Bion called ‘learning from experience’ [7] as opposed to more deductive and rational forms of learning. We badly need both.

[1]        A. Van den Bruel, M. Thompson, F. Buntinx, and D. Mant, ‘Clinicians’ gut feeling about serious infections in children: observational study’, BMJ, vol. 345, no. sep25 2, pp. e6144–e6144, Sep. 2012.

[2]        K. J. Hutchison and W. A. Rogers, ‘Challenging the epistemological foundations of EBM: what kind of knowledge does clinical practice require?’, Journal of Evaluation in Clinical Practice, vol. 18, no. 5, pp. 984–991, 2012.

[3]        T. Greenhalgh, ‘Why do we always end up here? Evidence-based medicine’s conceptual cul-de-sacs and some off-road alternative routes’, OF PRIMARY HEALTH CARE, p. 92, 2011.

[4]        I. Mcgilchrist, The Master and His Emissary: The Divided Brain and the Making of the Western World, Reprint. Yale University Press, 2010.

[5]        A. Bechara, H. Damasio, D. Tranel, and A. R. Damasio, ‘The Iowa Gambling Task and the somatic marker hypothesis: some questions and answers’, Trends in cognitive sciences, vol. 9, no. 4, pp. 159–162, 2005.

[6]        D. Ariely, Predictably Irrational: The Hidden Forces that Shape Our Decisions. HarperCollins, 2009.

[7]        W. R. Bion, Learning from experience. London: Heinemann, 1962.

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