It is July 1, 1962, the first day of my residency training. A second pediatric "intern" and I had been assigned to "City Hospital." Only a second-year resident and an attending physician were supervising us. Medicaid was 4 years away, our patients had no way to pay for care, and the four of us were all that the city could afford to cover pediatrics in its ward, nursery, clinics, and emergency center.
Interns were to alternate night call and I was up first. After lunch and check-out rounds, the second-year resident took me and the other intern to the nursery and said, "Pick a baby. We are going to practice resuscitation so you will know what to do when you hear, 'Dr. Altemeier, stat to L and D.'" At about 2 pm, the resident told me how to reach him and sent the other intern home. I was about to be the only in-house coverage for the next 16 hours. "Wait a minute," I said. "You haven't shown us where the bathrooms are." I felt this information would be needed almost immediately. "Don't worry, Altemeier. You will be fine once you get busy. Get to the emergency room before you fall too far behind," he replied. He was right, and I made it through the night. It was the first time I realized how good it feels to hear the birds begin to sing just before dawn.
It is now July 3, 1962. I feel better after a good nighf s sleep. Maybe I will survive internship. It is morning rounds and the other intern is almost finished presenting his cases: "This 9month-old black girl was admitted yesterday evening with lethargy and bacterial meningitis. She had been seen here the evening before last with fever and had been given antibiotics for otitis." Wham! I recognized her immediately. She had looked a little sicker than the others, but I had otitis to explain mis and her fever. I had missed the diagnosis and now she was barely conscious. What a disaster.
The girl began to improve in 3 days and seemed to fully recover during the next 6 weeks. But I was in bad shape for 10 days, so bad that my coworicers worried about me. As a student I had not understood what it meant to be responsible for patients. Concern (or fear or anxiety) was now an inherent part of making clinical decisions.
THE IMPORTANCE OF ANXIETY IN CLINICAL PRACTICE
Looking back, I mink I learned to use anxiety as a clinical tool at some point. Of course, anxiety is a motivator and helps to keep you honest and trying to "do whaf s right." I don't want a physician (for myself or my family) who is never anxious. However, I believe that anxiety can also be used as a clinical tool because it "watches over" clinical decisions.
This function can be illustrated by an example. Relevant to the topic of mis issue of Pediatric Annals, you have examined a 5year-old girl with vomiting, diarrhea, fever, and alxtorrtinal discomfort. Not surprisingly, your diagnosis is gastroenteritis. She is not dehydrated, so supportive therapy is all that is needed. But you have the reeling that something isn't right. Your conscious mind says that that is silly. It looks, smells, and feels like gastroenteritis, so why isn't it gastroenteritis? Your subconscious mind won't let go and you feel vaguely anxious. You can repress this, especially if the waiting room is full, or you can tap into mis and ask yourself, "Why am I anxious? Is it because the abdominal pain is more prominent man usual or somewhat localized? Is it because the amount of diarrhea is less than usual or out of proportion to the pain?"
Isn't the concept that anxiety can be a signal that you may not have full control an example of the role intuition plays in medical decisions? We do not talk about this much (it is not very "scientific"), but I bet most of you would admit that intuition plays a role here. Is this not part of the concept that medicine is an art? And what does it mean when someone asks you for your "gut feeling" about a patient? But using anxiety to self-monitor decisions goes beyond this because it implies the active, intentional application of intuition. One does not usually think about applying intuition, it just happens. Can it be used intentionally?
THE IMPORTANCE OF INTUITION IN DECISIONS
The really important decisions of life, such as whether you will get married and to whom, what career you will choose, and whether you should move and take a new job, are not made on a fully conscious level. These decisions use conscious analysis, but the final word seems to "come from the heart."
Every year, a few panicked fourth-year medical students would schedule an appointment with me because it was November and they did not yet know whether they wanted to do a pediatric or some other residency (eg, obstetrics, medicine, or surgery). More would know what they wanted to be, but would have no idea how to list or prioritize the places for training. My advice was something like, "Keep thinking about it, but don't obsess about not knowing. Some decisions are too important to be made by the conscious mind alone. You will know you are getting close when you vacillate - you are sure what you want to do one minute, but change your mind a few hours later. Soon you will wake up and be sure. This can happen as late as a week before match lists are due. But your situation is common, and it is rarer not to know by the time you have to submit your list."
This usually (but not always) turned out to be true. Anyway, I believe many or most of us make the really important decisions, including those regarding patient care, by collecting and mulling over pertinent information (consciously), with the final decision coming from (or being overruled by) intuition (from the subconscious mind). This may not hold for everyone. Some highly intelligent and analytical individuals seem to make all of their decisions consciously. They can fully explain all of their actions. Actually, there is probably a spectrum of dependence on conscious versus subconscious decision making, following some kind of bell-shaped curve. Do you see differences in the way your associates make diagnoses and formulate care plans? The important question is: Can intuition be applied more actively (as in the above use of anxiety to monitor decisions) in practice? I mean besides listening to that voice that says something is not right?
It sounds illogical and counterintuitive (no pun intended) mat the subconscious can be "used," but we do it all the time. We just don't mink about it. Here is an example of how to try this. You receive a request for a consultation. The case is complex and the patient's attending physician is not satisfied mat he or she has control of things. Subspecialists may have offered opinions, but mese conflict or the patient's problem crosses too many disciplines. The attending physician wants an in-depth general pediatric review.
Try starting from scratch. Instead of relying solely on the chart, do your own complete history and physical examination (a hands-on approach seems to help). If you still have not put it together, go to the literature and read about related topics. Then, be open for the case to suddenly fall in place and make sense. See whether somewhere along the way (probably not until sufficient data are available) the diagnosis and plan will "make itself known" to you. Be alert and don't fight it if the answers seem to suddenly "pop up" from nowhere, but be patient as well.
Be sure you don't fool yourself. Get a full database before taking intuitive reasoning seriously. And trust intuitive insight only if it fits all or almost all of the data. The insight should make sense consciously, even if the information had been too complex or conflicting to put together on a purely conscious basis. Give it a try.
This approach fits general pediatrics because it can cross subspecialty disciplines and does not depend on having seen the same situation previously. However, experience must play some role. I guess it may take years to develop clinical intuition in general. The bottom line is we need more research into how clinical decisions are made.
You may have surmised from this far-out discussion that this is my last editorial. I think it will mark the final step in my retirement from general pediatrics. Intuition tells me it is time to move on to the next phase. It has been a great ride and I don't think I would change much, even if I could. I have loved general pediatrics because of its variety. I was privileged to work during an era when 1 could take care of patients, teach, and do a little research in pediatric and neonatal intensive care units, emergency centers, and busy clinics and wards.
One of the best parts of my career has been editing Pediatric Annals. Thanks for putting up with me (I guess you had no choice). A special thanks to SLACK Incorporated and its staff, especially Shirley Strunk, John Carter, and Richard Roash. They have been perfect to work with - always supportive, but allowing me to do it my way (as illustrated by this editorial). And thanks to Elizabeth Haskamp, who typed my editorials late at night and after parties because I was always a lastminute person. Of course, it was my wife. Lesive, who really made my career happen.
Your next editor will be Dr. Stanford Shulman, Professor of Pediatrics at Northwestern University Medical School and Head of the Division of Infectious Diseases at Children's Memorial Hospital in Chicago. He will be great!