PLEASE NOTE: This is a minimally-edited transcript that originates from a program that uses AI.
Anita Rao
After about 15 years as a practicing anesthesiologist, Dr Ronald Dworkin knew what it felt like to be in the groove. He churned through cases throughout the day. He made decisions quickly and with confidence. Then he took a six week vacation, and on his first day back to work, while driving to the hospital, something came over him.
Dr. Ronald Dworkin
I felt uneasy. I wasn't sure how I would react in particular clinical situations. Something was off. I didn't know what or why.
Anita Rao
With no clear warning, one big thing he'd come to rely on for decision making seemed to be gone. His intuition. I had extreme
Dr. Ronald Dworkin
self consciousness and self awareness when compared to my usual state of mind. And it was hard for me at the time to comprehend what was going on inside my mind in any more detail. The unexpected had never really startled me, but now I sense some kind of inner harmony was gone.
Anita Rao
This is embodied, our show about sex relationships and your health. I'm Anita Rao. More people in my family are in healthcare than aren't. So it's not news to me that practicing medicine is both a science and an art. There are rules, best practices and data. But then there's something that's a little harder to describe.
Dr. Ronald Dworkin
It's more than an instinct. Instinct is sort of more visceral, I guess I would say intuition is just one of those mysteries in life that needs to be respected, because you can never know it. You can only believe it.
Anita Rao
Ron discovered how essential intuition was to his work on that first day back from vacation some 15 years ago, He's now retired from anesthesiology and devoting more time to his other passion, philosophy, and he's had a lot of time to reflect on that day. If this thing intuition is so important for physicians to make decisions, why is it so hard to understand, and what does it take to get it back to start our conversation, we go back to the beginning of Ron's story, when he started thinking about becoming a doctor in the first place. You come from a lineage of physicians. Your father and your grandfather were both doctors. Tell me a bit about how their experiences in the profession informed your decision to go into it yourself.
Dr. Ronald Dworkin
Well, that's interesting. Being exposed to medicine for two generations. I was interested just by learning about it second hand. I was good at science. I like science, and I want to make a contribution to humanity in my own way, and so I naturally gravitate towards medicine as a way to do all those things.
Anita Rao
Anesthesiology is the specialty that you chose, and it appealed to you because of your love of being alone with your thoughts. Tell me a little bit more for those of us who are outside the world of medicine, how the nature of this specialty aligns with your temperament?
Dr. Ronald Dworkin
I think you know every person, certainly every doctor, has to know himself or herself. I am not an organization man. I never was. I was never a back slap or a joke teller. I simply like to be left with my thoughts and my work and to do good at the same time. But I was not going to be a very social person in whatever work I want to do. Certainly, when the case of general anesthesia or even sedation, you talk to the patient before they go in for surgery, but the patient is asleep, and you are there wrestling with complications that might occur while under anesthesia, change, vital signs, decline, oxygen and so on, but you're not actually really having much interaction. You're there basically supervising yourself and making sure you're taking care of the patient and making sure the patient will wake up when the surgery is over. So you're not really involved in any kind of complex social milieu. It's not the nature of anesthesia, unlike, say, primary care, where you have a lot of discussions with patients, and you get to know the patients well, and you had natural chit chat. That's not really the way with anesthesia, a little bit before the surgery, but not too much.
Anita Rao
So one of the really important traits that you do need to be able to have and to hone is not panicking, but also really well honed sense of perception. Why is that perception and that intuition so important in anesthesiology.
Dr. Ronald Dworkin
First of all, you're right about you say about panic. Anesthesia has been called 90% sheer boredom and 10% sheer panic. So events can happen and change very quickly. So it's important that you don't panic and you can reason your way through calmly. The importance of intuition. Anesthesia occurs because not all the information that you wrestle with as an anesthesiologist is numerical. Sometimes it's intangible, unquantifiable. Years ago, I was called into the or for an emergency. When I arrived, I saw a new anesthesiologist, inexperience, and his eyes were wide open. He was panic stricken. He was standing over the patient. The patient's blood pressure had suddenly collapsed at the end of a symptom. GYN case involving spinal anesthesia, and the young doctor was forcing air into the patient's lungs at a fast rate to at least keep her oxygenated. And no one understood was going on. And at first glance, my own scientific analysis of the situation explained nothing. The data on the monitors explained nothing. But then my intuition kicked in, and sort of taking me to the heart of things, sort of enabled me to enter into sympathy with a young doctor, to grasp His essence, so to speak. While looking at him, I thought to myself, young panic stricken, rookie mistake, simple mistake. And then I glanced at the candy cane stirrups at the edge of the aura table, and suddenly the truth came to me as intuition. The patient's blood pressure had collapsed because her legs had been taken out of the stirrups too quickly, exacerbating the effects of spinal anesthesia. Forcing air into her lungs with a bag and mask only made things worse, as it kept the blood pooling her legs. So I told the or team, put the patient's legs back in the stirrups, and I told the young doctor not to breathe so fast for the patient. And so soon the patient's blood pressure returned to normal. Scientific analysis was not enough to yield the vital truth at that moment in time, it had to be intuition, understanding what these young anesthetials might be going through, that's what led me to the solution to the problem.
Anita Rao
So take me more into what's happening in your mind in that moment as you tell that story. I'm envisioning like watching you from the outside and seeing maybe your your movements change as this intuition kicked in. But what does it feel like in your brain and in your body when you are really in touch with that intuition.
Dr. Ronald Dworkin
That's I can't describe it in the sense it's more like poetry than than prose, because there is a mix of memories that are coming up, emotions, feelings, a sense of wonderment, a little bit of sense of confusion, and all these feelings and emotions memories are mixing together at a very fast rate, and all of a sudden you feel this impulse, a movement of direction that's telling you where to go and what to do. But if you're to look back and try to explain that impulse and say what it is, you can't because it's hard to describe, and the impulse is gone.
Anita Rao
Was it trained in you? If you think back to medical school, is there a moment that comes to mind where you learned a lesson around intuition?
Dr. Ronald Dworkin
I wasn't taught intuition in my training. I don't believe intuition can be taught. It sort of arises bit by bit over time. I've likened it to the experience of knowing your hometown, because you spend years growing up and playing in your hometown, you know your hometown from the inside. You're sort of in sympathy with it, and your hometown is a kind of a simple, indivisible experience, meaning you develop intuition about your hometown that way. And from that intuition, you can produce lot different sketches of your hometown, how the people might react in certain situations, and so on. But you can't do the process in reverse. You can't study hundreds or 1000s of sketches of that town and then develop an intuition about it. You have to have grown up there and lived there, and so in anesthesia, you can't teach someone intuition. You have to develop intuition by living and practicing anesthesia over the years. So anesthesia becomes your hometown, so to speak.
Anita Rao
So a number of years ago, you were halfway through your career, you had an extended break from the hospital, and what happened when you came back to work at your medical practice got you really thinking critically about how important intuition is in your job. And I want to break down some of the moments in that story. So take me back to that day and the first moment when you knew that something was off with your intuition and the feelings that you associated with that moment.
Dr. Ronald Dworkin
Well, as I mentioned, I started already noticed something was wrong when I was driving to the hospital. And when I got to the hospital, my first patient the day was a woman going for IVF egg retrieval in vitro fertilization, and she had been caught chewing gum a few minutes before. Now, there's a quasi official rule in anesthesia that an elective case should be canceled the patient has been chewing gum because chewing gum causes the stomach to secrete gastric juice, and it puts a patient a higher risk for aspiration while under anesthesia, which can be dangerous, can lead to a bronchospasm or pneumonia, possibly even death. But obviously, the woman, she wanted to proceed. She and her husband had put so much time, money and effort into IVF, and the egg retrieval has only a narrow time frame in which to be performed. So I hesitated over what to do, and the quasi official rule kept staring me in the face, and I felt uneasy about deviating from it. I knew I would have proceeded with the case before my Tom off from the hospital, but how I would have arrived at that decision? I couldn't figure out. I just know the earlier decision would have based on my intuition, and that would have been enough to undergird me when deviating from the rule. But now I was full of doubt about how to proceed.
Anita Rao
You write about how in anesthesia, there are these really crucial moments when you are able to see that there's a turning point between life and death. There's this critical inflection point. What was that point in her case?
Dr. Ronald Dworkin
The problem that arose first, it was a question of what to do whether proceed with the case. But the actual problem arose during the case, at the end, when she began to have what's called laryngospasm. Her vocal cords were clamping shut, most likely because gastric juice has slipped out of her stomach and pal. Down her airway, and action had to be taken. The question then was, how do I fix the problem? Usually, the problem is fixed with a very short acting muscle relaxant, and the problem goes away in about 30 seconds, and the patient comes back to breathe, but the patient had a very large burn on her leg, and that drug is contraindicated, and so I would have to use a longer a longer acting muscle relaxant in that case, but that made me not have to put a breathing tube in the patient. I never had to do that before. I was always able to use a short acting muscle relaxant. But how was I to know which one to use? The rules weren't that precise about in terms of how big the burn should be and when you should not use that short acting drug. I'd always made the decision in the past. My intuition always worked well, but this time it didn't, and so I was uncertain what to do. I hesitated. That rule kept staring me in the face, and I was sort of paralyzed.
Anita Rao
Why was your intuition offline that day?
Dr. Ronald Dworkin
I don't know. Most likely, I suppose, because I had been away from my practice for six weeks. It was unusually long period of time away. I had my scientific abilities, it was still intact. That wasn't a problem. But that's like flying on one wing. There's another component to practicing anesthesia and practicing medicine in general. You have to have a certain belief, because reason alone, scientific analysis won't get you through. And that component I lacked, I lacked a kind of a fundamental system of able to believe in something when there was no clear answer.
Anita Rao
Just ahead, we'll find out how Ron decided to move forward without the help of his intuition, and hear how we got it back. You're listening to embodied from North Carolina public radio, a broadcast service of the University of North Carolina at Chapel Hill. You can also hear embodied as a podcast, follow and subscribe on your platform of choice. We will be right back.
This is embodied. I'm Anita Rao. Dr Ronald Dworkin worked as an anesthesiologist for almost three decades. One day, about halfway through his career, he experienced what he describes as a loss of intuition. It all came to a head during his first case of the day, a woman undergoing anesthesia for an IVF procedure before things got underway, she was caught chewing gum, which raised the possibility for complications. Normally, Ron would have an easy answer for how to proceed, but without the support of his intuition, he was full of doubt.
Dr. Ronald Dworkin
When I was faced that situation, I tried to fill in the gaps with scientific data, with information, and I referred to the literature. I examined some of the algorithms that have been published in regard to gum chewing, and I asked for the opinions of some of my colleagues, and I tried to harness all the little bits of information available to me on the subject, but it wasn't enough that the literature offered no clearly defined answer, nor can my colleagues really refer me to one. There was no official universal rule that could be applied in all cases of gum chewing that I could use to guide me. And that's really the defect in relying on science alone or medicine. Doctors think that by gathering ever more data, they can get an accurate representation of reality that can substitute for knowing a problem from the inside with intuition. Many problems can be dealt with that way, but there are individual situations where there there is not enough data, and where there will never be enough data, because individuals, they vary so much and how they respond or behave, and no general rule or concept or algorithm can exist, and you have to rely on intuition to proceed.
Anita Rao
What did you share with your colleagues about what you were experiencing, this loss of connection to your intuition. Did you voice that out loud?
Dr. Ronald Dworkin
No, I didn't. I sort of hid it. I asked her their opinions about whether or not they would proceed one call like when I said, Should I go ahead and do this case? I'm not sure. And she laughed as of course, that's a no brainer. Of course, you should proceed. I sort of envy her as she had that kind of relaxed, comfortable way of deciding, the way I used to have before had gone on my break. She had her intuition still intact. She was able to believe in the right way forward, even though all the facts are not there, and proceed with certitude.
Anita Rao
So you have this kind of fork in the road. You have these journal articles that are not giving you clarity? You have your colleagues who are saying with certainty, like, of course, do it this way. How did you then choose to respond? How did you get your wits about you again to make decisions?
Dr. Ronald Dworkin
Well, it was difficult. I sort of, I guess you could say, went with the flow. I knew that all the times in the past I was able to proceed in such cases of IVF with gum chewing, and I used my inductive reasoning thought, well, all the other times in the past I was able to do this, and therefore I should be able to do this again. There was a question whether or not I should use spinal anesthesia in this case, because that would lessen the chance of aspiration. The patient would be awake during the IVF, but spinal and seizure, the patient would have to be numb for the waist down, there was a risk of a headache and so on. And I never had to do that path for any IVF patient had to chew gum. And so I thought, well, I hadn't do that. I didn't have to do before, so I probably shouldn't have to do it again. But again, that's not intuitive thinking. That's more like inductive analysis using science. That's not the same. And so I was still a little uncomfortable proceeding with the kind of more general anesthetic.
Anita Rao
Did everything turn out okay in the end for her?
Dr. Ronald Dworkin
Yes, it was fine. When I used a long acting muscle relaxant to get rid of her linger spasm, I had to insert a breathing tube, and she had the breathing tube for 45 minutes. When I brought the patient out with a breathing tube, everyone looked at me and was kind of reproach, like, usually, these cases don't need that. And I felt pretty stupid, but I took the breathing tube out in 45 minutes and the muscle relaxant ward off, and everything was fine. I still felt badly for having had to proceed that way, but everything turned out fine.
Anita Rao
You say that you felt stupid? Did you feel like shaken from a perspective of like, can I go into another room and do something else? Or like, how did that kind of feeling of stupidity sit with you?
Dr. Ronald Dworkin
I felt quite distressed. I would be sitting in the lounge that day and daring to space, and probably people thought I was fine, and I would go and grab my snack or my bagel and not say anything. But inside my mind, I was quite distressed and wondering if I would be living this way for the rest of my career.
Anita Rao
So how did your intuition return to you? Tell me about the journey to get it back. How long did that take?
Dr. Ronald Dworkin
About the day.
Anita Rao
Oh, so it came back in that same day. That's quick.
Dr. Ronald Dworkin
Yes, so it did. Now, how it came back? I don't know. It's as mysterious to me as intuition itself, and in ways, more mysterious in a way, than how I lost my intuition. All I can say is that gradually my heightened self consciousness and self awareness, which had assumed almost morbid proportions at that morning, began to fade. To use a metaphor, I became once again, like a child at play. I wasn't thinking on or dwelling on or over analyzing every thought and move I made in the operating room, somehow, I just fell back into the groove of everyday clinical practice, and intuition became as natural to me again as tension is to my muscles. That's happened
Anita Rao
Is there a moment that you can pin it to where you began to feel things turn around like a turning point in that day?
Dr. Ronald Dworkin
The one thing that that did change was my relationship with doubt, and that sort of offers me some insight into how I might ever gain my intuition. All during the time I'd lost my intuition, there was doubt there at my side, always dogging me and bothering me and saying that after any decision I made, are you sure? Are you sure? And it bothered me greatly. And I even imagined that before I had been away for that six weeks, I had never doubted. I imagined that there was some golden era when everything had been certain, and professionally speaking, I had been doubt free as a doctor. Gradually, over the course of day, I realized this is ridiculous, that my so called doubt free professional life, it was all just an illusion. And as I started to get more comfortable again living with doubt, my anxiety sort of gradually faded, and simultaneously my intuition gradually returned. That's the one change I noticed as my intuition began to return.
Anita Rao
I want to hear more about the kind of internal experience of this. I have this image of you sitting in that kind of lounge, you know, thinking off to yourself feeling stupid kind of being down on yourself as you moved throughout that day and felt like, okay, doubt is is going to be with me? It's going to be alongside me. Like, was there an element of kind of vulnerability there for you, where you could let someone else in or or talk more about that? Or was it still very much a solo experience of you going on this journey by yourself, a solo experience?
Dr. Ronald Dworkin
Yeah, maybe I don't want to confess weakness. Maybe I didn't want to cause alarm among my colleagues. I certainly didn't want to cause alarm among my patients. I didn't want to say that, by the way, I'm a doubting physician. Yeah, that doesn't feel great. It doesn't feel great. And so, so it's it's really much a private journey, and I think that's why a lot of this has not been written about a collapse of one's intuition. When doctors have been away, what answers also have been away for two years, not practice, then the professional organizations get involved after two years that they won't even hire you unless you take a refresher course. But if you've been away for a few weeks and six weeks, and you come back, and that first day, you're not you know, every professional, not just medicine, knows that they're a little rusty upon return, but the the feeling of doubt that comes with the Lost intuition is usually pretty short lived, and it's a private experience, and they're not talking about it. And journalists and psychologists who might write about this, they don't know about it, because the professionals don't talk about it, and usually bad things don't happen, like in aviation, planes don't crash and anesthesia patients don't die. So no one really knows about this phenomenon of a short term loss of intuition that picks up again pretty quickly. But it is there.
Anita Rao
Were there other times? During the course of your career where you had intuition, wobbles,
Dr. Ronald Dworkin
yeah, there was one case intuition. I said, it sort of works as a complement to science. And so I remember one time I was a doctor in training. I saw a patient in the ER. She was a very well educated, elderly, well educated, Middle Eastern woman who had been in the country for years, and when examining her, she struggled with the name of the current American president. She couldn't name the current vice president. She didn't know the name of the previous president. And my scientifically produced algorithm for estimating whether someone, someone's mental state is normal or abnormal, suggested there was something wrong with her mental state and that further evaluation maybe treatment were necessary, but my intuition told me something was wrong here. The algorithm was inaccurate. I sort of hesitated, and then when I probed deeper and talked with the woman about my concern for her state of mind, she laughed at me. She expressed contempt for American politics, which she said she had no interested in. And she said she knew all the names of the kings of France and all their mistresses too, and that they were a far more interesting crowd than the American politicians. And so I sense there that, you know, had been wobbling, but the general rule that doctors used to estimate mental status just didn't work here. Yeah, mental status fine, and that proved to be the case. And so it's example where doctors they really need their intuition, what might be called judgment, to balance their thinking.
Anita Rao
The way we've been talking about intuition is this kind of like a thing that you can't grab, you can't measure, it's hard to know when it's gone, until it's gone like it's imprecise, and you're a scientist by training, and so I'm curious if the imprecise nature of intuition is difficult in particular for scientists and for folks who are trained to be able to kind of measure and name and analyze things in a clear way.
Dr. Ronald Dworkin
Yeah, that's the that's the problem in science in general, because science doesn't really recognize intuition as an important phenomenon. The more scientific and technology oriented medicine becomes, the more intuition gets ignored, because intuition is more metaphysical than scientific in the sense that intuition can't be reached through any kind of objective study of material reality. It's all internal, and it's a problem in medicine. It's, I think it's, actually, it's getting a bit worse, because doctors increasingly rely on rules and algorithms to diagnose and treat people. And these rules are crafted through science after having observed 1000s of cases, and then the results reduce it with decision trees. If something is this and you do this, if something is that, you do that. But these guidelines, they aspire to make intuition irrelevant. You just follow the rule, you follow the algorithm we call the best practice guideline. But it doesn't always work out that way. I am concerned about one issue with the rise of artificial intelligence in medicine, because AI is pure scientific analysis. It takes hundreds, 1000s of billions of data bits and looks for the patterns, correlations, and then advises on the basis of that analysis. But AI cannot Intuit. It doesn't enter into sympathy with any individual case. It can't grasp its deep meaning or essence. It doesn't develop a feel for things the way one develops a feeling for one's hometown. So it just makes probabilistic calculations based on all the data it collects. But the bigger problem is that doctors rely on AI more and more, and scientific analysis reigns ever more. So premium medicine, I sort of hoped in the back of my mind that a resurgence of the humanities in doctors lives, whether you know, like instruction in college, that would help a great deal to bring back intuition into their lives. Emphasize the importance and humanities is particularly literature and philosophy. They emphasize intuition that comes up in all the novels and comes up in philosophy the importance of intuition. But doctors, they're not really exposed to the humanities much anymore. So they're not exposed to any kind of text that kind of emphasize intuition or praise intuition, praise the need for intuition.
Anita Rao
Do you ever think that trusting one's intuition as a doctor can go too far?
Dr. Ronald Dworkin
Yes, you need both, as I said, like wings on a plane, you need two wings to fly, so you have to have your intuition and you have to have your scientific background analysis. That's why, in expertise, there's no substitute for training, for reading books, for doing simulations, for studying, for learning logic, for learning, all the components of knowledge. But there's this other dimension that cannot be really be taught, but you have to recognize as being important, and you should, I'm not saying cultivate it, but you should respect it and listen to it. You might say, Well, you might be wrong, and that's true. The whole point of doubting the way forward, means you might be wrong. And intuition, it becomes useful when you do not have all the facts at hand, when you do doubt, in a way, it's kind of Iraq. When the word expert comes from the Latin word experi which means to try, doesn't mean to always get it right. Means to try to get it right, which means you might not always get it right. So that's the whole point of being if i. Professional, whether in medicine or as a pilot or anything, there is always an element of doubt. There is not always a sure answer.
Anita Rao
Is there a relationship between intuition and spirituality? You use the word metaphysical a lot of the language, or a lot of kind of the phrasing around intuition, I feel like we could maybe sub spirituality, and it would have a similar kind of conversation. Do you see a link between the two?
Dr. Ronald Dworkin
Yeah, I do. In a way, it's interesting. I wear this other hat as a political philosopher. So I was especially interested in medieval philosophy, which had a great debate over how we can obtain knowledge, especially religious knowledge, or spiritual knowledge. And one group at the time said biblical knowledge was all revelation. It was given by God to be taken on faith. And another group said, all biblical knowledge, even God's existence and plan, was accessible to reason, and we could know things, we just didn't have to believe in them or take them on faith. And say, Thomas Aquinas, who was probably the greatest of the medieval philosophers, he found a middle ground. Some truths came through Revelation, he said, and had to be accepted on faith alone, other truths were accessible to understanding through reason and intuition lay on the faith side the ledger. But the most important thing was that the two methods of understanding, faith and reason, or intuition and reason, they don't have any relation to each other. It's like the difference between the finite and the infinite, and that's the kind of what connects intuition to spirituality. There's a mystery about it, and we can't quite understand or explain and we never will be able to. So
Anita Rao
through all of this process and reflection, did you learn any secrets about how to get your intuition back after you've lost it?
Dr. Ronald Dworkin
No other than, other than if someone could retrace my steps. Maybe my problem is that I'm not comfortable with doubt. For some reason, people are thinking, I shouldn't having these. I shouldn't have doubts. Doubts should not be at my side. I was once doubt free, what's going on, what's wrong with me. And when you gradually recognize that no, the life of a professional is a life of doubt always. And if you can think about it that way, and you can begin to look at doubt at your side and think that's fine, I expect to live like that, that may accelerate the process of getting your intuition back if you recognize that might be the problem.
Anita Rao
There are also some habits and tools that you came up with in your own career as you move to part time work pretty early on, and you have this line that you wrote in your book, is that we say the solution for part time doctoring is that a part time doctor can't go part time in their mind, so you have to kind of keep those reflexes ready to go tell me about some of the tools that you learned to keep those reflexes accessible and make it so that that transition back and ability to connect back with your intuition could be A bit more seamless.
Dr. Ronald Dworkin
Well, first and most important, I never spend too much time away from the hospital in order to prevent my professional intuition from decaying. According to some studies, expertise in general, does decay rather quickly when you're away from one's craft. I remember there's a book by a research scientist, I think his name is, Robert Hoffman, called accelerated expertise. And he said that expertise decays after just being away from one's craft for just a few days. Usually the cognitive skills go first, that would include intuition, and then the motor skills second. In my experience, that's what was true. So I would generally try to avoid being away from work for too long to prevent that from happening. But in addition, while away, I would play various potential anesthesia scenarios over and over my mind, day and evening, to simulate my being there at work and to keep the connection with anesthesia practice. And so in some ways, by doing that, you could say, I never really left work. I was always tied to it, at least mentally. I I stayed in my hometown mentally, even when I was physically away.
Anita Rao
So you're like, you're on a beach and you're literally going through an anesthesia procedure. In your mind, absolutely
Dr. Ronald Dworkin
right? So I'm there on the beach, and I imagine a case, a difficult case, what do you do? What are you gonna do? And I would try to make it as difficult possible. And I thought, Oh, this is what I'll do, this one. And so yes, I would rehearse various scenarios, usually life and death, dangerous scenarios, and I would imagine what I would do, and I would do
Anita Rao
them. This essay that you have been talking about. You wrote it 15 years after the experience in the hospital. Why do you think this day in particular is one that has stuck with you so much that you've continued to kind of research and analyze it and turn it over in your brain
Dr. Ronald Dworkin
thinking back on these days, there's a certain psychological dimension to be an expert. I guess, as I thought about train of doctors over the last, say, 20 years, I thought it's getting short shrift that there's a psychological component to be an expert. We don't think about much anymore. And we think about it actually less and less because we think experts train by, say, deliberate practice, an idea that came became popular with Malcolm Gladwell outliers with the 10,000 hour rule, or the power of habit. Things over and over again, and you'll get better at it. And that's an important part of becoming an expert. You have to do things over and over again. You have to expand your envelope to get more comfortable with more complex cases. That's all very important. But what. Happens is the psychological component, which intuition is a part of, has generally been ignored in trying to understand expertise. And we don't think it's important, but it is very important, and it happened to come up, most obviously in the case of where I had lost my intuition on that time coming back from that six week period. And so there's something about the psychological component of expertise, which is very vulnerable, and it re crystallizes pretty quickly, but it's vulnerable, and if you lose a psychological component, and all you have is the power of habit, and you have your 10,000 hour rule and all the rest, that's a lot to be an expert. But it's not enough. There's an interesting psychology also to the expert, which is important, and I thought that was not being recognized.
Anita Rao
Ron is a retired anesthesiologist and a research fellow at the Institute for Advanced Studies and culture at the University of Virginia. You can find the link to his essay when I lost my intuition on our website, embodied w unc.org just ahead, I'll call up my brother in law, a gastroenterologist, and ask him about training the next generation of physicians on intuition and his own personal relationship with gut feelings.
Dr. Amit Gupta
In gastroenterology, we very commonly are often referred to our gut as our second brain, because there's just an endless number of connections and neuro pathways and neurotransmitters that are working through our gut, and we feel a lot of what we experience in real life as in our gut itself. And so I think we can all connect to that idea that there is something we just feel deep inside of us in those moments that often help us, help us act, or help us decide
Anita Rao
That's just ahead on embodied.
This is embodied. I'm Anita Rao. Today we're talking about intuition and its often mysterious role in decision making. As a case study, we've been looking to physicians, a group of folks who have to make multiple high stakes choices a day, we heard from Dr Ronald Dworkin, a retired anesthesiologist, about the day he lost his intuition and his reflections on getting it back. Ron left the field of medicine several years ago and has had time to reflect on intuition as part of his other career in political philosophy. But what about those doctors who are still in the trenches navigating new technologies in an increasingly digital world? What can we learn from how they are thinking about intuition and training it in the next generation? Luckily, whenever I have burning questions about the inner world of medicine, I have plenty of people to talk to. Most of my family works in healthcare, including my brother in law, to his trainees at UNC Chapel Hill. He's Dr Amit Gupta, gastroenterologist and assistant professor of medicine, but to me, he's just Amit. So I called him up for a chat, but this time, there were microphones on the first question I wanted him to field. What was his own definition of intuition as a doctor?
Dr. Amit Gupta
It's that ability to feel the right move in the right moment, to trust oneself, to believe in one's instinct, and to really be able to connect with people around you, and sense and feel what they're feeling, and use that as another method of understanding. What's most useful in a moment
Anita Rao
is there a particular story or moment that comes to mind in your career as a practicing physician that you think kind of exemplifies when you've had to really lean on intuition to make a decision? I
Dr. Amit Gupta
can think back to intuition as being very essential in procedural work, and as a gastroenterologist, a lot of my work is doing gi procedures, be that it's endoscopies or colonoscopies, and there are moments where you have to be able to rely on that instinct and what practice and repetitions and time has helped You realize is the right therapeutic choice in a moment. But conversely, I think a lot of the work I do is in clinic settings as well, and just talking to patients working through the things that are bothering them, or whatever their symptoms may be. And to me, a large part of intuition is really how I navigate those conversations and being able to put our computer aside and just sit there in that moment with someone and feel what their struggle is and what they're really hoping for from that visit, and allowing that to be able to help me think about the doctor I can be to them
Anita Rao
when you say doing a colonoscopy. Or an endoscopy, and using your intuition, like, tell me what that means in layman's terms. So there's, like, you know, there's a camera and you're seeing a particular thing inside of someone's body. Like, what? What are you needing intuition for in that moment to decide, is it like, which direction the camera turns, or is it something more specific?
Dr. Amit Gupta
Yeah, yeah, absolutely. So there are aspects of Gi procedures that I honestly think of as video games as well. Oh my gosh, and that there is this reality that every time you do a procedure, there's so many variances and differences, but on the same token, there's a lot that you have done before, and that is part of that process. But for a lot of Gi procedures, especially upper endoscopies, where we're doing a procedure to look in the esophagus or look in the stomach, we may be doing it to evaluate for a source of bleeding from the GI tract. And frequently that's something that we might be doing in an urgent situation or an emergent situation where we are looking for a source of that bleeding, and our goal is to both find that and to be able to treat that without making anything worse. And in those moments, there are times where we may come across, say, a blood vessel in the esophagus, and we have to assess if we think that vessel is at risk of bleeding urgently and or if it bled recently, and if we need to try to treat that most commonly with a rubber band to tamp that blood vessel down and reduce the risk of that bleeding again In the future, that moment where you have to deploy that band and select the spot to do that and ensure that you're able to do that without causing a complication, is trusting all of that practice that has come before to know this is the spot I want to place that band and that this is something I should do in this moment. Have
Anita Rao
you had any professional moments of feeling like you lost your intuition, or that it was wavering you're like in that moment of do I insert the rubber band or not, and then you start to second guess yourself?
Dr. Amit Gupta
There are unquestionably times where where I feel unsure about what I should do in a moment. And the reality of the way we work is that there are moments where we make these decisions purely independently, but we also are part of a community. And I think a huge part of medicine is being able to make those decisions, but have humility in all of the work we do. And so it's not infrequent that I trust in the community around me as well, and know that I have so many people that I can lean on and work with to help make some of these decisions. So there have been times where it is possible to call on someone who's in a neighboring room doing a procedure to get their opinion as well, and we all do that as a back and forth. But something in medicine that I've had to really learn, except it's I entered medical school with a feeling and a concept that medical training is going to help me know exactly what to do in each moment, and that the best like maximum medical training, if I really focus and dedicate to all of these things, it's going to create all this certainty in our practice. But it became very clear to me very quickly that medicine is only so much of a science and that we're constantly striving to learn and better understand things, but that's going to be the reality of medicine forever, is that it's a constant learning. And a huge part of being a physician is being able to be comfortable in that uncomfortable being able to accept and acknowledge that uncertainty, both for us ourselves as physicians and for our patients and in so doing, be able to act in those settings, but also be able to guide patients and find that common thread and help them navigate that space
Anita Rao
you talk about you as a young med Student, kind of going into this environment hoping for certainty. How were you taught to think about intuition in your medical school training? I think
Dr. Amit Gupta
the first time I ever even came across the word intuition as part of medical training was likely right at the beginning. I remember we all did a Myers Briggs Personality Test. I totally remember that. And I said, What does this mean for me? How does this apply to my own professional development and or my work as a physician, or how it might relate to patients? And I recall that being the first moment of trying to understand what intuition even meant. But. But thereafter, especially with my interest in medical education, as time has evolved, is that I think of it as more that fast instinctive thinking, that automated reliance on the gut feeling thinking in medicine, we call it system one thinking, or system two thinking, which is either like a fast, intuitive thinking versus a slower method of thinking. And we work on understanding that both of those forms of thinking are incredibly important and being able to do our work, and it's not being overly dependent on the intuition thinking, or conversely, overly dependent on the system to thinking, but rather being able to appreciate both of those, being able to develop both of those, and then finding that balance and understanding that we need to be able to switch between those at different moments in time. I know
Anita Rao
that you are someone who cares a lot about medical education, and since your own medical education have devoted a lot of time and energy and research to thinking about how to better the education experience for up and coming physicians. I'm curious, kind of on this thread of intuition, how you think about like, how medical education could better support physicians in balancing the two what comes up for you as you reflect on the necessary tweaks to the system?
Dr. Amit Gupta
Yeah, I love medical education. I get just an immense amount of joy out of working with trainees. And I think because I can greatly appreciate that process, and what that process was like for me, the feelings of vulnerability as you're trying to learn how to be a physician, and filled with this, like desire to ideally be the best physician you can as well. And so I do think about this a lot. In this past year, I've started teaching a class called Patient centered care. It's where we get to work with a small group of medical students from their very first day entering medical school. I have the luxury of working with seven students over the course of a year and a half, and specifically trying to help them learn physical exam skills, the process of history taking and importantly the next step of assimilating all of that information, applying clinical reasoning to be able to come to what they think is a most likely diagnosis and or treatment strategy. And a huge element of that is really this process of understanding those two types of thinking, paying attention and learning, you know, algorithms or data that helps you think about the things that are most likely, but be able to conversely, think about things that are less likely, or things you would not ever want to miss, and then switching to step two, thinking, to be able to think about the things you may see very infrequently, because it's those things that you see very infrequently that would couldn't be very easy to miss if you rely only on intuition.
Anita Rao
Hearing you talk about this makes me think about, I guess, some, some, some aspects of physicians that I don't love, which are like people with big egos. And I'm curious about what you think about the relationship between ego and intuition, because there's an element of like being able to trust your instinct, that I think in your intuition, that's really important in a strong decision maker, a good physician. But then there's also the physicians who have such a big ego about their own way of doing things that they're missing, you know, other important, relevant data. So how do you like check ego when teaching intuition, thinking about these young medical students who who you're trying to help form to be good physicians?
Dr. Amit Gupta
I couldn't agree with you more. I absolutely also can fully relate to that aspect. And I think if I think back to medical school, it didn't take long to realize there's going to be so much I don't know, and the only way to do a good job in medicine is 100% to leave that ego at the door and be humbled by everything that's before us. I think if we view ourselves as flawless or always assured or always confident, we're guaranteed to make so many errors and miss so many opportunities to better treat patients. And so there is an aspect of that throughout training. I think in medical school, you're assimilating a ton of information and just trying to get that foundation under yourself. But at each moment of training, it's understanding that you are in this constant training, and as educators or as faculty in a training environment, it's our job to constantly appreciate where trainees are in that process and be able to meet them in that moment and be able to. To both applaud the growth in decision making capability and the growth in responsibility, but also be the check when there is that transition, or when there could be that transition to feeling of overconfidence. We sometimes call it an error in medical thinking or in critical reasoning can be this step towards premature closure, and that's the situation in which we quickly, maybe, through that unchecked intuition, commit to a diagnosis without being able to entertain everything that is actually before oneself. How
Anita Rao
do you coach that? Do you say, like, I'm beginning to set an error of confidence. Like, how do you coach that in a young physician?
Dr. Amit Gupta
Great question I've I've definitely told a trainee that I was worried that we're missing things because we're overconfident, and it can be hard to to provide feedback very explicitly, but I think this is the aspect of feedback that's an art as well. But I think my goal is to try to help learners see those spaces for improvement on their own, and then to be able to work with them to break that down and use those opportunities as ways to share where intuition or overconfidence may have hindered our ability to provide better care.
Anita Rao
So looking forward to the future, we are in a new era of medicine. AI is being slowly in some spaces, quickly in other spaces, integrated or introduced as a tool into the healthcare practice, there is much more Digital Communication and Digital Literacy required of physicians. I'm curious about your thoughts on new and emerging pressures on doctors intuition and decision making in the years to come.
Dr. Amit Gupta
So reading Ron's piece about intuition, his feelings of loss of intuition in a moment in time, one of the huge things I thought about was that it very much was an argument against the ability of AI to replace a human physician, because so much of medicine does involve that art. So much of medicine, I think, is being able to rely on aspects of the human experience and what we feel in these moments, and being able to have these subconscious dots connect, right and AI is going to provide a lot of information. Be able to essentially spit out responses and probability based thoughts and ideas for endless number of questions. And so I think it's going to be incorporated unquestionably, and it think it can be very helpful in helping to develop what those possibilities are. But on the flip side, it it's still the physician that has to navigate all that information and be able to individualize each of those patient experiences, attempts at a diagnosis, attempts at a treatment, because medicine is the exact opposite of one size fits all.
Anita Rao
You can find out more about Dr. Amit Gupta and Dr. Ronald Dworkin at our website, embody w unc.org you can also find all episodes of embodied the radio show there, and make sure you subscribe to our weekly podcast. Today's episode was produced by Kaia Findlay and edited by Wilson Sayre. Nina Scott is our intern, Jenni Lawson, our technical director, Amanda Magnus, our regular editor, and Quilla wrote our theme music. This program is recorded at the American Tobacco Historic District North Carolina. Public Radio is a broadcast service of the University of North Carolina at Chapel Hill. I'm Anita Rao.