The Value of Clinical Intuition:  Kids also Experience Drug Side Effects 

Salar A. Khan Internist Chicago, Illinois

Salar Khan, MD, MBA, FACA, FCCP, DTCD, MCPS, worked as an Attending Internal Medicine and Pulmonologist at Karachi, Pakistan 1985-87. Dr. Khan also worked as an Attending Internal Medicine and Pulmonologist, Chief of Medicine, Chief of Staff and Acting Hospital Director, Al-Midhnab General Hospital, Under Ministry of Health,... more

Clinical intuition is difficult to describe. Personally, it is the art of integrating nonverbal information that a patient presents in order to reach a diagnosis, reducing the need for diagnostic testing. This is especially important in children who often react differently to procedures, tests, and other treatment modalities. Medicine is as much an art as it is a science, and this skill is definitely the former. 

In the practice of medicine, a holistic approach to patient care is often touted: one that not only focuses on the disease, but the whole individual. How can such a lofty goal be accomplished? The most skilled physician is the one who has the strongest observational skills in detecting clinical signs. These signs include behavior, appearance, and other observable signs. The clinical assessment begins as soon as an individual walks into the office. The gait, the appearance, and the mood. All these tiny things provide a wealth of information to the physician in the treatment of the patient, especially children, who are more vulnerable to emotional stress. These skills together comprise in part clinical intuition which can help us realize the ideal of holistic patient care. 

In my own career, clinical intuition has proven useful. From 1988-1993, I was an attending physician for internal medicine & pulmonologist at Al Midhnab General Hospital Saudi Arabia. One warm July night, we had a 6 year old child present to the ER with suspected meningitis. The chief pediatrician who was handling this case was explaining the situation to the father, when I happened to walk by while rounding my patients. I overhead him say that they would get a lumbar puncture done and admit the child. To this day I can’t tell you what compelled me to take a look. But I did. And I saw the child with his head tilted towards the right side: a right dystonia. Perhaps it was something in the child’s expression, the way he looked, or his demeanor, or maybe it was that the child wasn’t overtly expressing infectious symptoms like fever, headache, etc. All I knew was that my instincts were telling me that we weren’t dealing with meningitis. My mind was gravitating towards a medication side effect that I had seen countless times in my training. The anxious expression of the child was all the motivation I needed to step in and confirm the possibility my mind had hatched.  

Receiving permission from the pediatrician to evaluate the patient, I elicited a history from the father focusing particularly on medications. I learned that the child had vomiting bouts a couple days prior and was given metoclopramide. Afterwards, he began presenting with right neck dystonia later that day. This was a common side effect of the medication, which I knew from my past experience working in psychiatric wards. My diagnosis clinched, I asked the nurse to prepare a valium injection and to give slow intravenous. Once the injection was given, the child’s head began to rotate slowly back to normal like clockwork. Everyone was stunned. The father could not stop shaking my hand and the pediatrician was in awe. The child sullen-faced earlier, was overjoyed. This may seem like a non-replicable, isolated incident. However, I assure you that many physicians have had similar experiences. Now the question is--how do we teach this kind of skill?  

A possible answer is that it comes from exposure to many permutations of clinical cases and symptoms with the goal of treating the patient holistically, a conclusion supported by Brokensha’s review from 2002. Furthermore, I will add that the art of the physical diagnosis is an essential part of the intuition and is central to developing strong observation skills. During my training, we took an exam where a standardized patient was evaluated in 15 minutes, where the student had to rely on his observation skill, palpatory, and physical exam skills to come to a diagnosis. In Pakistan, with the lack of resources in many clinics, it was imperative to master this skill. With the passage of the Affordable Care Act, I see a similar discussion taking place in the United States. A class focusing on developing clinical intuition into our medical curriculum can be a starting point. Maybe experienced physicians can keep a journal of interesting cases relying on their clinical intuition and then pass it on. Clinical intuition is still a valuable skill in modern healthcare and is both a celebration of our roots as healers and a lantern to the future of our profession. 

References: 

Brokensha, Glyn. (2002). Clinical intuition: More than Rational? Australian Prescriber, January, Issue 25, 14-15