Occup. Med. Vol. 49, No. 1, pp. 37-41, 1999
Copyright C 1999 LJpplncott WlUlam3 & Wnklns tor SOM
Printed In Great Britain. All rights reserved
0962-7480/99
The importance of intuition in the
occupational medicine clinical
consultation
R. Philipp, E. Philipp and P. Thorne
Centre for Health in Employment and the Environment (CHEE),
Department of Occupational Health and Safety, Bristol Royal Infirmary,
Bristol BS2 8HW, UK
Clinical consultation involves unspoken elements which flow between doctor and
patient. They are vital ingredients of successful patient management but are not easily
measured, objective or evidence-based. These elements Include empathy and
intuition for what the patient is experiencing and trying to express, or indeed
suppressing. Time is needed to explore the Instinctive feeling for what is important,
particularly in present day society which increasingly recognizes the worth of
psychosocial factors. This time should be available in the occupational health
consultation. In this paper the importance of intuition and its essential value in the
clinical interview are traced through history. Differences between intuition and empathy
are explored and the use of intuition as a clinical tool Is examined.
Key words: Clinical consultation; emotion; empathy; evidence; intuition.
Occup. Med. Vol. 49, 37-41, 1999
Reamed 5 January 1998; accepted in final form 11 May 1998
INTRODUCTION
In the Journal of the Royal College of Physicians of London,
a recent discussion of the changing role of the consultant
physician reported that, 'there is clearly an urgent need
for clinicians to acquire the communication skills and the
confidence to share uncertainty with their patients, while
retaining their professional integrity'.1 D'Auria also
noted recently in this journal that, 'decisions involving
people will always have emotional aspects'.2 In addition,
it has been suggested that independent medical practitioners 'must offer those things which are not universally
available on the NHS: principally time, explanation, education, second opinions, and special interests'.3 Both
'science' and 'art' are, too, essential elements of
evidence-based care.1'4 These observations are important
to occupational physicians, as humans are social beings
who interrelate on both rational and emotional levels.
Perhaps in response, the NHS Executive now recognizes
the worth of services to NHS staff provided by psychological therapists.5 Furthermore, many patients, as well
as doctors, now tend to perceive illness as the result of a
complex interaction of social, psychological, physical
and emotional factors.6'7 Indeed, in general medical
Correspondence and reprint requests to: R. Philipp, Centre for Hearth in
Employment and the Environment, Department of Occupational Health
and Safety, Bristol Royal Infirmary, Bristol BS2 8HW, UK. Tel: (+44) 0117
928 2223; Fax: (+44) 0117 928 3840.
practice the key transactions are thought to be mysterious because they have developed out of an inarticulate
mix of intuition and experience.8'9 Interestingly too,
clinical experience suggests that many younger people
nowadays seem to put more value on the emotional side
of life than on purely scientific analysis.10'11 A study of
patients in cardiology, gastroenterology and neurology
outpatient clinics has also indicated that more positive
management of anxiety and depression might lead to
greater patient satisfaction and help to reduce the development of chronic somatization.'2 It has even been suggested for some physical conditions, such as myocardial
infarction, that it is unethical not to treat psychological
factors.13
Regrettably, however, although patients often instinctively know if a doctor feels for and with them, the
dysfunctional doctor—patient relationship persists.14
Accordingly, despite the present cost-conscious, sociopolitical environment of medicine, an understanding and
sympathetic approach still needs to be taken by objective
and scientifically trained clinicians.1'15 Too often patients
suppress information, not realizing its significance, fearing to admit to underlying tensions, or worrying that the
doctor is pressed for time.1 For example, although at
least 30 minutes is needed for each new hospital outpatient appointment the consultation can last less than
12 minutes,16 and in general practice the patient booking
intervals can be only five to 10 minutes.17 Unfortunately
38 Occup. Mod. Vol. 49, 1999
too, if a patient hints at something that is not followed
up, they might never allude to it again. Concern that
time constraints do not allow all possibly relevant factors
to be explored therefore reduces the effectiveness of a
clinical consultation. Doctors were warned recently that,
'patients are teaching us that we are not doing well. If we
know how to listen, then patients can teach us more than
books ever can'.18 For these reasons, reflective listening,
empathy and intuition are part of the diagnostic and
therapeutic process.
DIFFERENTIATING BETWEEN INTUITION
AND EMPATHY
Intuition is 'the ability to follow hunches and to "know"
something without being able to offer a conscious reason'.19 Earl Spencer described intuition as 'the distinctive feel for what is important', and the greatest gift of his
late sister, Diana, Princess of Wales (his Funeral Service
Tribute, 6 September 1997). In 77K; Concise Oxford Dictionary intuition is denned as: 'immediate apprehension
by the mind without reasoning'; empathy is denned there
as 'the power of projecting one's personality into, and so
fully understanding, the object of contemplation'. The
terms can be interpreted in many ways but for health
professionals their elements include sensing and understanding what the patient is experiencing, trying to
articulate, withholding or wishing to suppress and consciously appreciating what should be done to help a
patient The Germans describe empathic aspects of this
relationship as 'Einfuehlung', in which the medical practitioner has to try and ignore as much as possible their
own emotions.20 Nevertheless, in serious illness, the
emotional agony experienced by patients cannot always
be shared with doctors.21 Instead, real empathy and solace are sometimes given by untrained ward-workers.22
Doctors are failing in matters of empathy and intuition, perhaps because of the present emphasis in diagnosis and therapy for 'evidence-based' medicine, based
on measurable experience. Reassurance, understanding
and emotional support are at risk of becoming marginal
activities.10 Yet, genuine interest and empathy are important in clinical practice.23 Doctors who are particularly
appreciated by their patients include those who discover
and deal with patients' concerns and expectations about
their problems, those whose manner communicates
warmth, interest and concern, and those who volunteer a
large amount of information and explain matters in
terms that are understood.24 Core values identified by
the British Medical Association for the profession also,
include the 'ancient virtues of competence, integrity,
confidentiality, compassion, and commitment practised
with an enquiring and impartial mind'.25
The need in clinical practice for empathy and a synergy between the factual, rational and emotional is paramount. Empathy is, as Zinn26 reported, 'a process for
understanding an individual's subjective experiences by
vicariously sharing that experience while maintaining an
observant stance. It is a useful tool in the medical
encounter as it provides the physician with a fuller, more
personalized view of the patient, and it provides the
patient with a sense of connectedness to the physician
that may allow him/her to more freely express his/her
emotional distress'.
It is apparent that empathy builds on self-awareness;
the more open we are to our own emotions, the more
skilled we will be in reading feelings. The capacity of
knowing how another feels refers back to the original
Greek word, 'empatheia' — 'feeling into', a term used
initially by theoreticians of aesthetics for the ability to
perceive the subjective experience of another person.15
Empathy is the source of intuitive understanding.27 It
leads to instinctual sensing of what a patient has left
unsaid, thinks consciously or unconsciously and what
should or should not be brought out in the consultation
or undertaken to help the patient.
THE IMPORTANCE OF INTUITION
Medicine in contemporary society may be failing
because doctors do not listen to pleadings behind the
spoken word. Basing clinical action mainly on evidence
for the effectiveness and efficiency of different therapies
can give a feeling of safety and security and makes sense
in many high-technology hospital-based specialities. In
most clinical practice, however, the evidence base is not
the only determinant of action.9 Therapeutic action
should weigh all the clinical, emotional and personal factors as well as any associated social problems, mood
swings and inherent stability of the individual if effective
help and advice is to be given.1'15'28'29 The art of healing
cannot be quantified.29
The recent enormous increase in evidence-based
knowledge has overwhelmed the profession with new
facts. There are, however, differences between knowledge and knowing. The French for example, distinguish
between 'connaitre' (used when people or things are
known or recognized by the senses) and 'savoir' (used
when referring to knowing facts, knowing as a result of
study, and knowing how to do something).30 Emotional
disturbance, insecurity and related depressions and anxiety are too often considered of less importance than
physical problems and mainly treated with drugs.31"33
Nevertheless, despite limited evidence of its effectiveness, most patients in primary care settings would prefer
psychotherapy.33*34 A Jungian approach, basing therapy
on the adjustment of emotional as well as physical factors,
with medication only as an adjunct, has much to offer.
For example, the perpetuation of unexplained somatic
symptoms, commonly encountered in occupational
health practice, is best understood in terms of an interaction between physiological processes, psychological
factors and the social context, for which an integrative
approach is recommended.7 Even in an apparently
straightforward physical illness like measles there is usually an associated emotional problem which needs an
extra soothing word or action at the right moment. This
is not simple psycho-analytical theory but a fundamental
approach. Jungian thinking tries to re-establish the concept of an underlying imbalance between feeling and
R. PhiSpp et a/.: Intuition In the occupational mecficlne clinical consultation
thinking; within each of us Jung sees the adjustment and
development of the male and female side of our existence, logic and emotion, and the associated upheaval in
the mind, as essential aspects of therapy.35 The Jungian
approach shows similarities to that of the religious healers of the Middle Ages in the value that it places on
mystical or religious elements in the therapeutic relationship.36'37 There is something inexplicable that should not
and cannot be interfered with in the deeply rooted,
inherited characteristics and the foundation of individual
personality, like all physicians over thousands of years,
Jung's 'new' ideas are, on closer inspection, developments in emphasis and attitude with an added injection
of the new, but never a complete break with the past
Often an understanding of the patient's belief has to be
brought out in therapy and the supernatural and unexplained discussed openly to release emotion and
resentment.38
Unnecessary suffering should therefore not be tolerated and nothing must interfere with the sacred duty of
physicians to all humanity. It is not for nothing that emotion and factual thinking have a physiological and anatomical basis in the plexus which intimately connects the
neocortex of the two cerebral hemispheres with the
amygdala of the limbic system.15 Nature shows us that
both sides of the brain must interact as a natural, flowing
process of interchanging information. It provides the
physiological infrastructure of reason and emotion in our
behaviour and attitudes.39
HISTORICAL SWINGS IN EMPHASIS FOR
THE RATIONAL AND EMOTIONAL
ELEMENTS OF LIFE
History teaches us that doctors' attitudes to the rational
and emotional elements of life and what is intuitively
appropriate in the consultation, reflect the attitude and
mood of the society they work in. Over the centuries
there have been swings of opinion for the relative importance of factual knowledge and the impact of emotion.
The delicate balance between these two extremes of
understanding was first discussed by Hippocrates,40 and
the significance of empathy in therapy has been a topic
of medical controversy ever since. Thousands of years
ago, based on the idea of continuous cyclical fluctuation,
Chinese philosophers taught us the necessity of the balance of 'yin' and 'yang', the opposing intellectual and
intuitive forces responsible for harmony of everything in
life.29*35'36 For example, it was one of the essential duties
of the Emperor to adjust the equilibrium of everything in
life and doctors were an executive arm of this attitude.
They knew already that full health requires settling any
imbalance of the two basic complementary forces, yin
and yang. Chinese doctors reflected the attitude of their
society in defining health in terms of adjusting the individual to fit the structure. They saw and treated sickness
as some kind of incongruity with society, an imbalance of
the relationships of the internal organs, or both. Balance
between all the factors affecting life had to be reestablished.
39
The Greeks struggled throughout the classical period
from the sixth to the third century BC with the fundamental issues of necessary adjustment to the relationship
of factual evidence with subjective emotions. In a genealogical tree modern Existentialism has been traced back
to Socrates' saying 'Know Thyself', which was at the root
of his attitude to life.41 The Sophists, representing that
which is emotional and inexplicable, opposed Plato's
rational philosophy. It was reasoned that objectifying disease could lead to a rigid and unimaginative approach by
the physician.41 This struggle has many similarities with
our present-day underlying philosophical conflict. Even
in the sixth century BC, Thales was already looking for a
permanent force underlying the apparent chaos of
change. He had faith that such a force must exist in the
seemingly permanent disorder. He believed in a hidden
permanency and unity, discernible by the mind if not by
the senses. Pythagoras, in 530 BC, speaks of the separatism, dualism and relationship between the spirit and the
mind.41 He pointed out that the mind as much as the
feelings needs continuous realignment.
Christianity over the last two thousand years has
shown repeated swings between the two extremes of
restricting the individual and allowing hedonistic individual expression.36 At times, strict control through the
power of the mind has been uppermost in the leadership
of the Church, but then there have also been periods
when the enjoyment of earthly pleasures has overwhelmed the Church's traditional law. These swings in
balance ruled medicine at different periods in the Middle
Ages. Sometimes the emotional religious side was so
strong, and the body so sacred, that medicine would not
interfere with the sanctity of human anatomy as it was
given by God, and dissection was a crime. There were
other periods when doctors felt that they had the right or
even the duty to examine the body scientifically in order
to increase knowledge, and they were supported by the
attitude of the Church at these times.
Our modern problems of unifying the rational and
emotional aspects of life are, it seems, part of a pendulum swing. At present we have considerable imbalance
between that which is objective and measurable, what
can be demonstrated and proved by test or previous
experience, and what we instinctively and intuitively feel
is right.42 Present thinking in medicine seems to overvalue the rational at the expense of the emotional. If pursued to its extreme, this could lead to health care
becoming debased to a commercial commodity in which
health professionals are paid merely for knowledge and
technical skills. This attitude could lead to something
approaching inhumanity, and is far from our vocation as
healers. New movements in society are, however, now
coming to the fore reminding us of the very strong ethical foundations of medical practice,43 and the Hippocratic Oath requiring doctors to be Samaritans. These
new movements as ways of dealing with the underlying
imbalance of the rational and emotional aspects of life
can be seen in the increasing emphasis on healthy living,
healthy cities, schools, workplaces and hospitals,44 and
the many new schools of meditation, different religious
groups and other emerging activities and complementary
40 Occup. Med. Vol. 49, 1999
therapies which contribute to the stabilization of society.29 They help to counterbalance a current trend for
personal freedom with its sometimes unstructured, independent thinking, lack of focus on constructive problem
solving, and individual need for excessive external stimulation, heightened emotional experiences and immediate gratification. These personal needs can interfere with
a collective responsibility for order and balance in nature.
The doctor, working with individual patients, often has
to address, interpret and attempt to help adjust these
imbalances.
INTUITION AS A CLINICAL TOOL
As with learning to use empathy effectively through trial
and error,45 intuition is a carefully learned skill which has
to be developed within oneself as a therapeutic tool. It is
an essential ingredient which enables us to gain knowledge without direct evidence in an empathic encounter.
In psychotherapeutic terms it has been described as a
'cognitive-affective capacity used to accomplish an
empathic mode of perception', which in turn allows the
therapist to be in touch with all aspects of the patient's
experiential state.46 However, whilst empathic skills are
believed to be both measurable and teachable,26'47 intuition, being in part an unconscious activity, is not readily
accessible to objective measurement and is therefore
more controversial. Indeed, it seems unlikely that medicine can ever be entirely free of value judgements.48 Its
use is, nevertheless, widely recognized in nursing practice but acknowledged as a professional risk in ethical
and legal terms.49-50 In current nursing theory the role of
intuition in Benner's model of nursing skills acquisition,51 has been the subject of debate over the lack of
empirical validation of the concept.52 Benner describes
'intuitive grasp' , which distinguishes the expert nurse
from a non-expert, as being 'available only in situations
where a deep background understanding of the situation
exists, based on a broad base of knowledge and experience'.51 As Spiro reported,47 medicine is 'both science
and narrative, both reason and intuition'. A great deal of
learning, self-examination and reflection on previous
clinical experience is therefore needed before a doctor
can be fully conversant with the use of intuition in therapy. Although encouragement is often important for
patients with hesitant or timid personalities, how far and
when to stimulate must be developed through experience
and training; there are dangers in using one's own influence at, for example, the wrong moment,20 or in a controlling hierarchial way which might be damaging and
intimidating Q. Lait, counsellor, 1997, personal communication).
The use of intuition as a clinical skill involves methods
of picking up leads from the patient suggestive of unoffered but important material, and qualities that should
be developed by the physician to help bring out information being sought from the patient Important leads may
be identified from heightened awareness to cues from the
dress, behaviour and attitudes of the patient, patterns of
response to gentle exploration and direct questioning
such as changes of mood, posture or speech, avoidance
of subjects, and flights or association of ideas, listening
for any aside comment and oblique reference to persons
or situations, and looking for gestures of joy, despair or
other emotion and for changes of affect during the consultation. The clinician must also, through understanding, training and experience, be able to identify with the
problems and situations of different patients, dress and
behave in accordance with their expectations, use appropriate language, terminology and metaphors they can
readily identify with, foster an emotional sixth sense for
what is unspoken, alluded to, disguised, unrecognized or
suppressed, and be able to interpret all the cues and
information obtained in ways that are supportive and
meaningful for the patient
CONCLUSIONS
Medicine continues to change with society and the personal relationship which once existed between doctors
and their patients, and the benefits of the extended clinical encounter which that entailed have largely disappeared. Nevertheless, the underlying requirements for
empathy and fundamental understanding remain and it
is still the role of physicians to develop insight and identify the true needs of patients. An intuitive approach to
our clinical work encapsulates the rational and emotional
aspects of patient support and ensures that the hidden
part of a complaint is always kept in mind. This
approach has a psycho-neuro-immunological basis,15
with links to the endocrine system.53 Fostering it can
improve the quality of our consultations. Finding the
right approach to take with each patient should allow a
ray of sunlight to penetrate the mind. It is the job of a
physician to seek out the best rays and share their
warmth with those who should be our greatest friends,
the patients. For them, we ourselves are still the most
important medicine. In occupational medicine we must
therefore always show that we care.
ACKNOWLEDGEMENTS
In preparing this paper we are indebted to our following
friends and colleagues for their comment and encouragement: Marilyn Armitstead, Pearl Davies, Kit Harling,
Clare Hayward, Pat Jennings, Debbie Jones, Jenny Lait,
Patricia McKellar, Binnie Philipp, Jan Price, Anne Rossiter, Stephen Szweda, Sally Tanner and Annette
Young.
REFERENCES
1. Rigge M. The changing role of the consultant physician:
what sort of doctor. J Royal Coll Phys London 1996; 30:
505-508.
2. D'Auria D. Credo [Editorial]. Occup Med 1997; 47: 267.
3. Coleman R. Career focus: the independent medical practitioner. BrMedJ Classified 1997; 315: 2-3.
R. Phlpp et al.: Intuition 'm the occupational mocDdne clinical consultation
4. Greenhalgh T. Is my practice evidence-based? Br Med J
1996; 313: 957-958.
5. Department of Health. NHS Psychotherapy Services in England. Pub. 1996: H56/001 0900 IP 5k Sept 96 (04); 1996:
112.
6. Webber V, Davies P, Pietroni P. Counselling in an inner city
general practice: analysis of its use and uptake. Br J Gen
Prac 1994; 44: 175-178.
7. Mayou R, Sharpe M. Treating medically unexplained
physical symptoms. Br Med J 1997; 315: 561-562.
8. Heath I. The Mystery of General Practice. London, UK:
Nuffield Provincial Hospitals Trust, 1995: 53.
9. Hennen B. Being the best medical practitioner you can be.
New Zealand Fam Phys 1993; 20: 149-151.
10. Spencer J, Stacy R. Interpersonal skills are being taught
better, but more work is needed. Br Med J 1997; 314:
1203.
11. Philipp E. The physician, the aged and society. New Zealand Fam Phys 1995; 22: 1-3.
12. Hamilton J, Campos R, Creed F. Anxiety, depression and
management of medically unexplained symptoms in medical clinics. J Royal Coll Phys London 1996; 30: 18-20.
13. Williams RB, Chesney M. Psycho-social factors and prognosis in established coronary artery disease: need for
research on interventions. J Am Med Assoc 1993; 270:
1860-1861.
14. Magnusson S. Oh, for a little humanity. Br Med J 1996;
313: 1601-1603.
15. Goleman D. Emotional Intelligence. London, UK: Bloomsbury, 1996: 352.
16. Sellu D. Have we reached crisis management in outpatient
clinics? BrMedJ 1998; 316: 635-636.
17. Wilson A, McDonald P, Hayes L, Cooney J. Longer booking intervals in general practice: effects on doctors' stress
and arousal. Br J Gen Prac 1991; 41: 184-187.
18. Anonymous. Editorial. Br Med J 1996; 313: 951.
19. Anonymous. Editorial. Views and reviews: Minerva. Br
Med J 1997; 314: 912.
20. Philipp E. Encounter and emotion in the therapy of emotional disturbances seen as a new sub-specialisation of
general practice. New Zealand Fam Phys 1981; 8: 59-62.
21. Saunders C. A personal therapeutic journey. Br Med J
1996; 313: 1599-1601.
22. Philipp E. The doctor is paralysed. New Zealand Fam Phys
1994; 21: 128-130.
23. Philipp E, Philipp R. Racial tension and the medical practitioner. New Zealand Med J 1986; 99: 854-856.
24. Anonymous. Editorial. Patients views of general practice. J
Royal Coll Gen Prac 1983; 33: 5-7.
25. British Medical Association. Core values for the medical profession in the 21st century. London, UK: BMA, 1994:
Report of Conference held on 3-4 November 1994.
26. Zinn W. The empathic physician. Arch Intern Med 1993;
153: 306-312.
27. Farry P. The empathic response — an experience in the
holographic domain. New Zealand Fam Phys 1985; 12:
91-93.
41
28. Philipp E. Some thoughts on the future relationship of
hospital and general practitioner. New Zealand Fam Phys
1982; 9: 147-148.
29. Capra F. The Turning Point: Science, Society and the Rising
Culture. Flamingo, Harper Collins, 1983: 516.
30. Knight TW. Living French, Third Edition. London, UK:
University of London Press Ltd., 1972: 255.
31. Philipp E. Medical ethics, a live and changing concept.
New Zealand Fam Phys 1991; 18: 115-118.
32. Hale AJ. ABC of mental health: anxiety. Br Med J 1997;
314: 1886-1889.
33. Hale AJ. ABC of mental health: depression. Br Med J
1997; 315: 43-46.
34. Salinsky J, Curtis Jenkins G. Counselling in general practice. BrJ Gen Prac 1994; 44: 194-195.
35. Young-Eisendrath P, DawsonT. The Cambridge Companion
to Jung. Cambridge, UK: Cambridge University Press,
1997: 332.
36. Watts AW. Psychotherapy East and West. New York, NY
(USA): Pantheon, 1961: 204.
37. Jung CG. Psychology and Alchemy, Second Edition. London,
UK: Routledge, 1968: 569.
38. Philipp E. Belief: an essential factor in modern therapy.
New Zealand Med J 1977; 85: 192-194.
39. Herbert J. Stress, the brain, and mental illness. Br Med J
1997; 315: 530-535.
40. Lloyd GER. Hippocratic Writings. Penguin, 1978: 380.
41. Guthrie WKC. The Greek Philosophers from Thula to Aristotle. London, UK: Methuen & Co. Ltd., 1950: 168.
42. Weed LL. New connections between medical knowledge
and patient care. BrMedJ 1997; 315: 231-235.
43. Caiman K. The profession of medicine. Br Med J 1994;
309: 1140-1143.
44. Speller V, Learmonth A, Harrison D. The search for evidence of effective health promotion. Br Med J 1997; 315:
361-363.
45. Bellett PS, Maloney MJ. The importance of empathy as an
interviewing skill in medicine. J Am Med Assoc 1991; 266:
1831-1832.
46. Lichtenberg JD. The empathic mode of perception: an
update. In: Empathy and Intuition. JAmAcad Psychoanalysis 1993; 21: 485-500.
47. Spiro H. What is empathy and can it be taught? Ann Intern
Med 1992; 116: 843-846.
48. Kerridge I, Lowe M, Henry D. Ethics and evidence-based
medicine. BrMedJ 1998; 316: 1151-1153.
49. Leners DW. Intuition in nursing practice: deep connections. J Holistic Nursing 1992; 10: 137-153.
50. Davis-Floyd R, Davis E. Intuition as authoritative knowledge in midwifery and homebirth. Med Anthropol Quar
1996; 10: 237-269.
51. Benner P. From Novice to Expert: Excellence and Power in
Clinical Nursing Practice. Menlo Park, CA (USA): Addison-Wesley, 1984.
52. Paley J. Intuition and expertise: comments on the Benner
debate. J Adv Nursing 1996; 23: 665-671.
53. Taylor MB. Comparison: its neglect and importance. Br J
Gen Prac 1997; 47: 521-523.