How Accurate is Your Clinical Spidey Sense?
Do you ever walk into a patient's room and just know they are sick. Not sick as in "yeah, this patient needed to call the ambulance but I can deal with this medical issue", but sick as in "oh #$%&@&!, this guy's about to code, get the crash cart STAT". Working in the emergency department, I have developed somewhat of a Spidey sense. Without looking at a monitor, taking a single vital sign, or even speaking a word to the patient, there are times I can tell someone just doesn't look right.
Most people have a hard time believing that working in the emergency department can become routine. But, it does. Often, the louder patients in the ED get the least attention. Drunks yelling "I need a sandwich" and patients hollering out of their rooms asking nurses to grab them a blanket are quite obviously breathing and oriented to their surroundings. While customer service could be called into question at this point, the urgency of a particular health situation usually is not.
Most days, there are only a limited number of injuries people can sustain and internal medicine problems that can go down. Fortunately, as a nurse practitioner my skill set has developed accordingly the longer I have practiced. Even in that crazy, what was that person thinking?! situation, the ED is equip to handle just that, emergencies, so things perhaps don't seem as serious as they normally would. I am clinically and emotionally prepared to handle serious situations. But, occasionally, something goes above and beyond the norm and demands urgent attention.
Urban Dictionary defines Spidey sense (yes, there is an official definition) as "Derived from the 'Spidey sense' of the comic book superhero Spiderman, it is generally used to mean a vague but strong sense of something being wrong, dangerous, suspicious, a security situation". In other words, Spidey sense is the intuition that something bad is about to happen. In my job as a nurse practitioner, this sense is essential to doing my job well.
As healthcare providers, we hone our intuition for when something is acutely wrong, for when the patient with symptoms of a urinary tract infection is actually septic, or for when a patient with chest pain just looks like they are having a STEMI. While I am aware that I have developed a sort of Spidey sense for detecting acutely ill patients, I wanted to know the data on these types of situations. Based on my experiences, it seems that the physicians, NPs and PAs with whom I work are often correct when it comes to their first impressions. But, just how accurate are these impressions? Can we really rely on them when it comes to our practice?
Studies on clinical intuition, making judgements without a particular awareness to our methods of reasoning (i.e. Spidey sense), have been met with mixed results. A 1998 study published in the European Spine Journal, for example, found that physicians were epic failures when it came to assessing level of psychological distress in back pain patients. Experienced spine surgeons in the study achieved only a 26% sensitivity in identifying distressed patients. Other studies, however, have found healthcare providers to be quite good at predicting clinical outcomes using intuition alone. One 2104 study found that nursing staff and physicians were quite good at predicting patient's in-hospital mortality upon the patient's arrival. Both nurses and docs accurately identified those at increased risk of dying.
Another interesting study published in the Annals of Family Medicine looked at clinical intuition breaking down the thought processes behind that Spidey sense. Authors identified three types of intuition. Gut feelings, the most common form of clinical intuition, alerted providers as to a cause for alarm but did not lead to snap judgements or clinical decisions. Gut feelings simply put the provider on high alert. In the second form of intuition, recognitions, providers formulated diagnoses quickly with very little information. Despite the lack of concrete evidence, providers were confident in their judgements. Lastly, insights occurred after extensive information gathering and an initial lack of clarity as to the situation. Insights were the "Aha!" moment leading to a diagnosis. Gut feelings can be helpful in alerting providers to the severity of a situation. Recognitions, however, can be dangerous because they may lead to omitting parts of the clinical process resulting in unfounded decision making.
As nurse practitioners, we must pay attention to our hunches, that Spidey sense, if you will, that alerts us to the idea that something could be wrong with our patients. But, we must be sure it doesn't color our judgement too strongly. If weigh our first impressions more heavily than clinical evidence, we risk misdiagnosis. Initial impressions can mislead us at times, so they aren't a substitute for completing the clinical process.
How accurate is your Spidey sense? When has it been right? Wrong?
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Want to know more? Here's an interesting read on the accuracy of clinical intuition.