Intuition and Imagination
Souls have complexions too: what will suit one will not suit another.
Middlemarch, George Eliot
Visions appear even to those whose eyes are shut.
De Anima, Book III, Chapter 3, Aristotle
We have enjoyed the appetizers. We have sipped on the pre-dinner drinks. Now it is time for the main entrée. It is time to get to the heart of the matter. It is time to speak of intuition and imagination.
In order to do so, a brief review may be helpful. In the previous small essays, I hinted at a kind of system, or, to be more apt, a process. This process was loosely deconstructed into three parts (which is a problem in and of itself and to which I hope to address in the next essay on presence-the briefest description of the problem being that it cannot really be deconstructed at all and to do so is to misunderstand the nature of the process of the art of medicine, however it is necessary to describe it in such a manner as to make it understood in simple prose).
What were those loosely described parts? First, there was the wide-angle view in which the physician tacitly observes the patients. He “takes them in”, so to speak, in order to develop the larger picture. This might be thought of as a myriad of subconscious clues and intimations that are understood in the gut and at the base of the spine. Often this process can be begun from the doorway without the patient’s realization. This is the art of gesture interpretation and of simple observation. The ever-so-hunched gait. The quality of the patient’s clothing, make-up, fingernail polish. The unconscious style of speech and subtle mannerisms of humanity that may reveal so much to the careful observer. Much can be gleaned, for instance, by how a man takes care of his feet. We might subconsciously note the quick flash of fear in the eyes or the slightly increased work of breathing at rest. Or perhaps it is the thousand-mile stare of the demented and the desperation and despair of their caregiver seated next to them, often gently caressing the tremulous hand of their spouse who is still so close and yet so very far away indeed. It is these visions of a greater whole that begin before a word is spoken. This is one kind of attention that we must bring to bear on the encounter.
Then there is the empirical science that we apply. We allow the patient to speak and we listen. We lay our hands upon the patient. We palpate. We observe. We auscultate. We use our senses. What is that smell? Pseudomonas or Staphylococcus? Ketones? Melena? Nicotine or cannabis? Strep throat? With time, our olfactory cues become almost automatic. In the modern era, we glance at the telemetry monitor and the pulse oximeter. We might review the ECG done in triage or take note of the blood sugar. This is a different kind of attention (of a more focused, scientific and granular mode) that must be brought to bear.
Finally, we must take stock of both our tacit intimations and our explicit observations; of the whole and of the parts. The second mode of attention must be folded back within the first. We take this newly discovered patient in front of us and apply it back upon our initial intuitions, developed over time through the experience of so many thousands of patients seen thus far, and we formulate a differential diagnosis. We begin to think about how to rule in or rule out a diagnosis. Will testing be required? If so, what type of testing? Blood work? Imaging? Perhaps the diagnosis is entirely clinical. Will medication be required? Analgesics? Antibiotics? It is here where possibilities are discussed with the patient and, with their involvement as much as is possible, decisions are made about how best to proceed. This requires a certain kind of moral imagination. What would they like to have done? If the patient is unconscious or unable to participate in their care, what do you think they would like to have done given their situation or, more critically, what would it feel like to be in their position? Would they want the same as you if they knew what you knew? It is here where the moral imagination, otherwise known as empathy, must be applied, not too heavily and not too lightly, but brought to bear just-so. This is absolutely essential. In a perfect world, a plan based on shared decision-making is agreed upon and the encounter ends.
This highly idealized version of possible events requires two important concepts I’d like to touch on; that of intuition in the first part and imagination in the third part. The second part I touched upon when discussing the physical exam and I will forego further discussions here other than to note that all three parts are critical and intimately relate to each other.
Intuition then is the tenuous reception and understanding of elegant and subtle information, often transmitted subconsciously by the patient, through both passive and active observation. It is pulling back a little to try and take in a fully contextualized whole. It may take an effort to observe in this way, especially initially in one’s career, but once begun, observations flow both passively and actively, subconsciously and consciously, from source to receiver; from patient to physician. While it seems likely that some people are simply better attuned to having sound intuition than others, good intuition can always be made better and is attained by degrees over many years of experience. In this sense, it takes hard work and good reason to improve one’s intuition (conversely, good intuition makes it easier to reason well and the two concepts seem to create a positive feedback loop with each enhancing the other over time). It also requires an ability to sit back a little and trust one’s instincts in order to act upon them and interpret them appropriately. As such, good intuition is difficult. It is always difficult to let go a little and it is especially difficult for people who have received intense training in empirical, inductive methods that require active management and planning. After a while, such training makes it difficult to trust in anything that has not been verified by rigorous scientific data. This is especially so when the alternative appears to be a nebulous sort of gestalt.
Good intuition can lead the astute physician to ask better questions and to hone in on certain aspects of the physical exam that point toward a more accurate diagnosis. It is often a “hunch” that leads to the perfect question being asked and all of a sudden critical information is revealed that otherwise might not have been simply because the patient didn’t see it as important. All of a sudden, a grander and more complete picture begins to crystallize out of what was perhaps a murky constellation of signs and symptoms. Again, and I cannot stress this enough, intuition hints at a greater whole. It puts the patient into a larger context that is specific to the patient and so it steps back with a kind of passive receptivity and gives us a wider and more complete understanding. Patients, after all, are not isolated in vacuums but live within a complex web of relationships and social dynamics and it is our tacit, often unspoken intuitions that begin to hint at this broader truth.
Once we have begun to parse this out we apply an entirely different type of attention, that of honing in, to the patient and specifically what his problem may be. This second part, the inductive and scientific part, is far more productive when it is applied with some knowledge, whether implicit or explicit, of the patient that was gathered initially through intuition.
Finally, with both firm empirical data at hand and sound physician gestalt present within us, we can appeal to our moral imagination to help our patients in the third “step” of this process. What I have been calling our moral imagination is another word for empathy-our ability to imagine ourselves in our patients’ shoes. This quality of the excellent physician is bestowed at birth upon us all to varying degrees however I think it too can be trained, made stronger and formed into an important part of our practice as well as an important part of our day to day lives.
In essence, it is the imagination, our ability to metaphorically transport ourselves into our patient’s perspective, that allows the physician to take his empirical investigation into the acute problem that brought the patient in to seek care in the first place, and refer that back upon the overall context of their lives, information gleaned through intuition, as much as is possible. Put another way, this critical step is the reincorporation of the scientific and empirical back into the grander context of the patient’s life so that the way forward for them is aligned with their own goals and limitations in mind and yet also set within the physician’s capabilities and full understanding.
The physician then, in the act of empathy, is not simply becoming the patient-he retains his own independence-but he is entering, with the patient’s consent and hope, into a part of another person’s subjective universe. There is a kind of sharing of the soul at play and it is indispensable to the physician’s art. Without empathy, the patient is nothing more than an interesting science experiment-a Frankensteinean collection of parts. Yet, with too much empathy employed, the patient threatens to become melded with the physician and objectivity may be quickly lost. Treatments may be recommended based solely upon what the physician would want rather than uniquely tailored to the patient’s specific circumstance. The moral imagination requires a kind of via media to avoid being too absent and thereby too callous and uninterested in the patient’s goals and hopes or to overwhelming, leading to a conflation of the physician’s own emotions with the patient’s. Both errors, one of omission and one of commission, can prove fatal to the overall goal of empathy-that of reintegrating the empirical science of our medicine back into the context of our patient’s life in order to tailor it specifically to their needs.
Aristotle in his De Anima (On the Soul) describes an important role for imagination in his epistemology but is clear to separate it from concepts of sensory perception or even mind. For Aristotle, it seems that imagination is built from the slow, progressive accumulation of our sensory perceptions over time and yet it is neither sensation nor mind, per se, but rather a tool of the intellect. St. Thomas Aquinas picks up this baton and notes that imagination is the active intellect that receives particular sensory data from our senses (our passive intellect) and pulls universal ideas from those individual and particular sensations. Our senses see an individual cow and our imagination makes the leap that there is a universal concept of what a cow is. It is from our sensory data and through our imagination from which we develop an idea of universals. Now imagine (as human beings can) that instead of cattle, we are considering pain, hope, shame, love, fear or the great mystery of our own mortality.
I make this brief and very ridiculously underdeveloped aside to make the point that it has long been thought that it is our imagination that helps to make us what we are as human beings. To be a physician is to take care of human beings and yet to be a physician is to be a human being. We must therefore use the tools at our disposal as human beings to understand those whom we would profess to help. Our uniquely human ability to empathize, to use the moral imagination, is what allows us to take care of others like us. The moral imagination is the keystone to bringing out intuitions about the context of our patient’s lives and the empirical data gleaned from our encounters with our patients back into the original context of what it is to be, not human, but that particular human. It is therefore what allows us to link the unknowable other-subjective with the knowable scientific-objective through our own humanity. We do not fully understand our patients nor do we fully become them but rather we live for them and in so doing we are both changed.
It seems to me then that in order to succeed, the skilled physician must be endowed with both intuition and imagination. If possessed of neither, the physician is nothing more than a technocratic scientist and his patient the material object of his empirical inquiry. This physician would be better served as an engineer or mechanic. If possessed of intuition but not imagination, he will be able to understand the patient fully as a whole, within the context of the patient’s unique circumstances in the world, but will not particularly care. This type of physician will be instantly recognized by any patient retaining a spark of lucid dignity within them and will be unable to retain patients so long as they are not psychotic, demented or intoxicated (and even these patients can usually tell when they are treated as something unimportant-something to be dealt with rather than someone to understand). Finally, the physician with imagination but without intuition will care deeply for his patients and will have the requisite technical ability to perform a physical exam and order and interpret the proper tests but he will not be able to understand the patient in any meaningful way. There will be no context and no ability to understand the patient within the milieu of that patient’s life; within his goals, interests, abilities, weaknesses, support system, family, friends, employment, culture, faith, desires, hopes, goals and fears. All the empathy in the universe is useless without an understanding of the patient as a being in the world with her own unique hopes, fears, desires, obligations and commitments.
The first physician sees not a fellow traveller but a complex machine requiring mechanical improvement in order to operate more efficiently. The second physician sees a grand forest but does not care for any particular tree within it. The third physician sees only the tree and cannot understand how it relates to the forest around them both. All three are clearly pathologic variations of the art of medicine. The wise physician, always building on experience, must hone his intuition, know his science and always be open to his own moral imagination-to his ability to be empathetic. To achieve such a balance is a difficult art. It takes time to hone and cultivate this type of a skillset but it is here, I would like to argue in the future, where the natural joy and satisfaction that resides in medicine will ultimately be found.