How to Quantify a Nurse’s ‘Gut Feelings’

I had a nagging sense that something was wrong, but I couldn’t articulate it.


Comments: 225

  1. Ms. Brown is right not only about nurses trusting their instincts and speaking up but also the need for the care team to listen. This collaboration worked as it should when we brought our coughing and feverish infant son to the emergency room at Morristown Memorial Hospital (Morristown, NJ) five years ago. After a careful exam he was diagnosed with a not uncommon case of Respiratory Syncytial Virus (RSV). After a consultation it was determined we could take him home and follow up with his pediatrician in the morning. When the ER nurse came in a short while later to help complete the discharge, her “gut” told her this case was on the serious side and, in her words, “she didn’t like what she was seeing.” With our discharge papers in her hand she brought the care team back in, talked them through what she was seeing, and they agreed that something wasn’t quite right. He was admitted right away and his condition worsened overnight as treatment intensified. Happily, after a scary few days, he rounded the corner and never looked back. We are always grateful to the nurse who trusted her gut and to the team that valued her instincts — even if was something they couldn’t quantify.

  2. Great essay. In the case of hospital admissions, nurses spend far more time with patients than physicians do. And even if they don't interact with the family of the patient, they observe these interactions.

    In my time as a medical educator for a hospital system in the Mid-Atlantic region, I was -- quite simply -- astonished that interns and residents on rounds didn't ever ask nurses about the patients they were rounding. My role was teaching these novice physicians about the importance of communication skills -- what many refer to as bedside manner.

    In healthcare, communication must forefront a systems approach and nurses are incredible resources that could (and often do) provide vast amounts of information that can't be gleaned from a chart.

  3. During my career in Internal Medicine, starting when I was an intern in 1969, the first thing I did before going into the patient's room was ask the nurse how the patient was doing and ask her if she had any suggestions. I learned very early in my career that the nurse could save the patient's life and very often my reputation. Somehow, the nurse has never been high on the totem pole at the hospital. Doctors ignore nurse at their peril.

  4. @Alan Feingold; Could not agree with you more. I credit nurses with a lot of my success as an internist, and welcomed their input on the wards and the ICU. On one occasion I was advised not to leave the unit for lunch just yet, even though the patient had seemed stable to me on morning rounds, and within minutes all the clinical signs one could want manifested in a crash. Always trust the senses of a good nurse.

  5. Well, this is timely. My brother has has two re-admits, with serious setbacks, following a 'successful' June 21 back surgery.

    Fortunately, since last bounce-back to hospital, in mid-July, kept for another 3 days, he has managed to stay home.

    But if anything goes haywire again, we will be asking: are you using the Rothman's Index?

  6. How old is your brother? What comorbidities does he have?

  7. Back in the days of no work hour limitations (36 on 12 off) I started my internship at Maimonides Hospital in Borough Park, Brooklyn. During orientation a second year resident gave us a word of advice. Listen to the nurse about the patient's condition. They spend more time with the patient and can pick up clues about the patient by their interactions.
    Five decades later it is still good advice.
    Dr Ruth Jacobson if you are still out there. Thank you

  8. @Teaching Doc
    Maimonides was a great place to train. Was Dr Grob your chief. Keeping the ratio of patients to nurses low and giving RNs time at the bedside is what results in great care. The quality of care and outcomes is heavily dependent on the nursing care. Smart docs listen to the nurse!

  9. Dr Grob was the chief.

  10. When will we admit that death is not always the worst thing that can happen? Why should we expect an 87 year-old patient to live on and on? At 82, I dread the thought of being caught in the American health system, which will refuse to help me die comfortably of old age.

  11. @jani No one of any age should die because of poor medical care and using age to excuse it is appalling. There is no indication that they wanted to live “on and on”. There can be a great quality of life for older adults. Much depends on cognitive status. You sound like you want a cut off age for medical treatment, remember you will get old too.

  12. @jani

    Please, if you were in the same position, and in good health otherwise, why not roll the dice for a few more years? The afterlife is seriously overrated.

  13. Palliative care doctors will
    focus on comfort.

  14. I value a nurse’s opinion in a visceral way I can’t deny. I thank them for their perspective constantly. Yet the general notion that an 87 year old woman’s failed procedure merits consternation may be more of the problem than the visceral information’s denial. Accuse me of a cold heart, or ask yourself what you say when articles percolate about the desperate plight of shore line property owners in the face of rising tides. I have both elderly parents and shoreline property, but a sober perspective is called for, as well.

  15. @Boxengo OK, since you ask: You have a cold heart. Saying someone is 87 or someone is rich is not an admirable diagnostic tool.

  16. Thank you for this piece. There are so many aspects of case taking and understanding our patients that are methodical and logical, happen in a predictable order and include a good clear review of systems. Care in and out of the hospital setting also includes nurses and doctors observation skills, being keyed into the kinesthetic parts of the experience with a patient. Our observations are so essential and of course they are most important because of the questions they lead us to ask. When I teach naturopathic medical students, we always include this aspect of being a health care provider. In our time of EMR which has providers noses in computer screens and less with the patient, this piece is a clear reminder that we must also prioritize connecting with the patient. So the Index described here and the use of AI based on big data is important. And connecting with our patients and honing our observation skills is also where we find the art of medicine.

  17. @amy rothenberg ND Naturopathic? Do you mean osteopathic or allopathic? 'Naturopathy' is not a medical field, and 'naturopaths' are not doctors nor med students.

  18. I think that the problem here, is that when expert RNs have this feeling, and we get them often, we need the skills and education to analyze, and articulate our findings to physicians. It isn’t enough to “push here and there”. We need to be ready to to clearly outline our findings, and create a plan to protect the patient. Nurses need advanced critical thinking skills that are not taught in all nursing programs, and also the ability to communicate their findings in a way that physicians can hear them. And when that has been done, to no avail, nurses must be able and willing to advocate more aggressively for the patient. Nursing is the most difficult baccalaureate program to complete because it is a very demanding profession, and we wear many hats. But patients in hospitals are sicker, and it is only getting harder to do our job well. We do often save lives when we pick up early signs that a patient is starting to fail, and this is a gift when it works well, and a curse when we remember the ones we couldn’t save. We all have a few of those, and while painful, it makes us better the next time.

  19. The patient is not "starting to fail." The patient was failing before she got there. That's why she is there.

  20. I was with you until you said that nursing is the most difficult undergraduate degree to complete. First of all—where’s your data? As a second career nurse with a first BA in comp lit from an elite school and later returned to the same elite school for a BSN, the difference was laughable. The comp lit degree was MUCH harder and taught me critical thinking and writing skills that allowed me to ace the BSN program without really even trying.

  21. Wait -- where is the evidence that nurses' gut feelings and the Rothman Index are ever in line with each other? Have these gut feelings ever been tracked and shown to be accurate indicators?

    This nurse is haunted by a single event that happened "years ago." How many times since then has she had a gut feeling of impending calamity that was not followed by calamity? Has she forgotten these times, or dismissed them because they're not so intense a memory?

    If every nurse's gut feeling of impending calamity is followed to the end Ms. Brown proposes, will we have an even higher epidemic of over-testing, over-treating, and the resultant medical errors?

    This article has only anecdata, when what it really needs is actual data.

  22. @Capri
    Logical Positivism died in the '70s.
    Continuity of observation is real data. Years of experience is real data.

  23. You must be a doctor.

  24. @Capri: Isn't that the point of the article? Correlation doesn't equal causation, recall? The situation may not fit neatly into a tight little box. Wouldn't you rather be safe than sorry?

  25. Also crucial to being an excellent nurse is the ability and inclination to listen carefully to the patient’s family member(s). Close family can sometimes pick up on the patient seeming “off” when medical staff cannot, and sometimes that family can articulate in what ways s/he is off. The nurse can then tune in to the signs and/or can intervene with the doctor on the patient’s (and family’s) behalf.

    I cannot say enough about the ER nurse who listened to me this past spring concerning what I noticed in my supposedly fine-for-release family member.

    Credit also goes to the doctor who then listened to the nurse, asked to speak directly to me, and emphasized how important the info I provided was. She admitted my family member. Within hours, my fm had a high fever and trouble breathing. The story ended well after a seven-day stay.

    Again — the happy ending began with an excellent nurse who paid careful attention to what I was saying and then followed through ...

  26. Nurses spend more time with patients than doctors do. I would want my doctor(s) to listen to their “gut instincts” as indicators that need lab work, documentation, or further diagnosis. Doctors without nurses would be something like an oxymoron.

  27. This idea sounds like another beeping machine to me, another way to convert the patient-doctor/nurse relationship into a patient-machine relationship. The other troubling thing is the idea that the metric for successful patient care is whether you can keep that person alive for a few days longer, which seemed to be the case in this article. What about quality of life in this new data driven way of managing patients? I am a person, not an automobile, yet it seems that medicine looks more like how my car is fixed these days.

  28. Not a believer in "gut" feelings but attribute to a cognitive "sense" when a patient is declining. A good nurse notices very subtle changes: slight change in VS, color, mentition, etc. And then, the nurse needs to work in an environment where that "sense" can be shared, acted upon, not derided or ignored. The best physicians ask and listen. That's very rare. Preventing codes is boring. But, that has been my aim for 4 decades as a nurse. 100% successful to date.

  29. I too have been fighting that fight for 4 decades . At least now we have “rapid response” teams. Usually the only way to get an ICU bed, instead of “watching” them until they arrest.

  30. I was a junior resident at UCLA. A patient I was responsible for had undergone a partial nephrectomy (partial kidney removal for a kidney cancer) earlier that day. It was about 02:00 a.m.. I had gotten home maybe an hour or so before that. I had been on call the night before and was whipped. I had just dropped into a deep sleep when I got a page from a nurse caring for the patient. When I called her she said that the "patient looked vague". I asked her what the patient's vital signs were, what the patient's urine output was and what his labs showed. All were normal. She remained insistent that the patient "looked vague".

    I sensed her discomfort. I turned to my wife and said "I am going into to hospital to assess a 'vague patient'".

    By the time I got there, the patient had turned from "vague" to profound hypovolemic shock. We resuscitated him and he walked out of the hospital upright rather than feet first. Were it not for nurse Gina recognising "vague" the patient would have died.

    From that point on, I never questioned the insights of the nurses directly dealing with the patients. They have a sixth sense and are the best advocates for patients. I have beat this concept into my residents/registrars for decades since. God bless the bedside nurses/sisters.

  31. You are to be commended. To leave the comfort of bed when exhaustion dominates is an admirable act. It would seem that males too have intuition.

  32. One of the most important aspects of our work is that it helps nurses communicate with physicians. Unfortunately the story I’ve heard too often from nurses is your story exactly, except that after the labs and vitals are reported as normal, the physician says “Why did you call me?” and hangs up. That nurse, especially a new nurse, which many are, is shut down... and will be very hesitant to make the next call... likely to the detriment of care for another patient.

    With the Rothman Index graph, which is based in part on the nurse’s “head-to-toe” assessments, the nurse can see a falling score... and this concrete data gives him/her more confidence in engaging with a physician. The nurse is not always “right”, but the fact that the discussion takes place, helps to provide better care. And we’ve seen results in a prospective randomized published study.

  33. I am glad that you took this nurse seriously, but as a nurse I’m embarrassed that the best she could come up with was “vague.” What the heck does that mean?? Instead of arguing for more AI in health care, why isn’t brown arguing for better education for nurses, particularly in the area of data collection, assessment, and presentation to physicians in a shared language. This is what I gradually learned how to do — but in NP school, not RN school. Nurses should find ways to convert their “sixth sense” into actionable, well-articulated data—and maybe then their valuable insights will be recognized as such. Not just by physicians who learn the hard way to “trust the nurse.”

  34. The key word in the story and in all the comments is listen. I have a family member in the hospital with sepsis because nobody listened to her.

  35. @Raven Senior
    And Serena Williams could have died after childbirth because the hospital staff didn't listen to her at first when she felt an embolism coming on. A patient who has had previous health issues should be listened to.

  36. Having been a nurse for 40 years I appreciated this article. I also appreciated some of the remarks from physicians acknowledging the value of a good nurse, both for them and for the patients. Most nurses give their all to provide quality care to their patients- long days with few bathroom breaks, if lucky, a short lunch, documentation demands ever increasing. The Rothman index is a good tool to quantify subtle changes in a patient. Sadly, staffing patterns often are insufficient to provide patients with safe, quality care.

  37. In 1991, my 3 year old underwent a complex heart repair. Among many of her post-op complications was one that she was unable to wean off the respirator for several weeks. It was frustrating and puzzling to all of her very fine,skilled doctors and specialists on her team until one of her ICU nurses noticed that her belly didn’t draw in evenly or bilaterally during breaths. This nurse’s keen and patient observation skills led to a diagnosis and another step toward my daughter’s recovery. Talk about ‘gut instinct’ (pun intended).

  38. I find it incredibly hard to believe that the patient's hemorrhagic stroke didn't result in any focal neurologic signs. Rather, what I suspect happened, was this: The nurse paged the doc and and said: "The patient is confused and has slurred speech" ....and the physician responded with :"And so do 50% of hospitalized, critically ill blood cancer patients...." and so thought nothing much of it and attended to other more-urgent sounding matters first.....If, on the other hand, the RN had fully assessed the patient, she would have noticed (a) that patient's speech was not "garbled" - it was aphasic; and (b) that patient did not have "confusion" - she had an acute change in level of consciousness.... If those objective findings (aphasia and obtundation) had been communicated to the physician, I promise you that s/he would have come running!! Code strokes are taken very seriously, and have been since the late 1990s.

  39. @GBR - A fine example of how an arrogant physician rationalizes ignoring a nurse's "gut feelings" - otherwise known as finely-tuned heuristics sub-consciously acquired through years of experience. In response to "and so do 50% of hospitalized, critically ill blood cancer patients...." the nurse would reply, "but I don't call you about 50% of hospitalized, critically ill blood cancer patients, do I?" Just because he or she did not use the precise language you would like, you ignore his or her warnings at the patient's, and thus your, peril.

  40. @GBR
    Ha! Man, if that was the case I better be making the big bucks too! I'd be real bummed out if I had all the education and experience you do that I could assess a payment in the same exact way.... but I was getting half the paycheck. Know what I mean?

  41. Amen. Thank you for illustrating this. The nursing profession has spent far too long developing its own language for the shared phenomenon that we and physicians observe in our patients— going so far as to develop an absurd sounding taxonomy of nursing diagnosis. (If you want a good laugh, check out “disturbed energy field.”) Most nurses roll their eyes at this, but it is still being taught!— even in elite nursing bsn programs (I graduated in 2009).

    I love being a nurse and caring for patients as I do full-time, but I found my educational experiences in nursing school at various turns frustrating, laughable, and surreal. The real education came in the science classes (anatomy, physiology, microbio, chemistry, pharmacology, pathophys, et al) and at the bedside, not in “professional nursing 101.”

  42. We need to get rid of the phrase "gut feeling" when it comes to trying to make sense of a patient's changing status. It is not a phrase that communicates anything of value and is not respected by physicians (and it shouldn't be). Such "feelings," as the writer articulated, are not at all feelings but "are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment." They need to be described as clinical observations with objective data. Physicians may still not take our comments seriously but let's start by getting rid of this idea that our gut is doing anything other than tell us when we're hungry.

  43. If I am in the hospital, and a nurse has a gut feeling..I'll take her advice and hope doctors do too.

  44. @lmsseattle
    sorry, but 40 years of ER nursing, and it IS a gut feeling. I am proud to have kept my 6th sense intuition intact. hurray for the gut feeling!

  45. Google " microbiome"

  46. I don't want one more machine to substitute for the warmth of a hand on mine or a kind word. Suppose the machine failed? Maybe a nurse who listens to her guts would be available?

  47. A few years ago my new young associate physician walked into our office at the hospital late at night and sat down to begin her overnight shift. She answered a page and then got up and headed for the door. I asked, “What is it?” and she said, “I don’t know, the nurse said to come right now.”

    That’s the kind of doctor I want taking care of me when I’m sick.

  48. In my medical experience, insurance companies control the diagnostic system. Doctors know this. So no matter what your malady, you will be diagnosed based on insurance company directives, not on medical results. Nurses work under this flawed system. And obviously they may be frustrated because they can not change it. It is important to return medical diagnosis to practitioners and take it away from the insurance companies.

  49. @Mark Hermanson. Can you explain further how diagnoses are based on insurance company directives? Thank you.

  50. I am a retired hospital RN, and I can not put my finger on it, but there was many a case when my instincts prevailed over what was on paper. These involved not only insidious changes in a patient's condition, but also errors of my fellow co-workers. The latter, because of an unwritten code of professional courtesy, needs to be handled diplomatically. However, it can not be ignored, not at the risk of the very person whom we have an ethical responsibility to care for.

    One commenter, and I thank him, mentioned how crucial nurses are in the healing and treating of the ill...and also how at times our assessments are not taken seriously by our doctors. I thought back at a time when I stood up to a head nurse's assessment and then the patient's doctor who was reluctant to heed by urgency. He did, and he later thanked me for detecting ventricular contractions which were life-threatening. As a final thought, I was taught to take notes on all my patients. Even if I did not have time to run to the desk to officially chart a situation, I took a few seconds to write down any red flag occurrences. Documentation is invaluable.

  51. I learned the complementary lesson early on in my medical training. One night I was paged by a nurse who wanted me to place an order for a sleeping pill for a patient who couldn’t sleep. When I asked what the trouble was, the nurse told me that the patient was just anxious. As an new intern terrified of making a mistake, I decided to go and check on the patient. It turned out that she couldn’t sleep because she was in florid heart failure and struggling to breathe. She was urgently intubated and sent to the cardiac ICU. Acting on the “gut” assessment of the nurse would have killed her. The lesson I learned is that no one should base patient care on someone’s gut feelings. If you have a concern, go and evaluate the patient! This applies to nurses, doctors and every member of the care team.

  52. Guess what? Anyone having a operation that requires general anesthesia almost always means you were “on life support.” One is intubated, requires fluids and often vasopressin drugs and other things that “ support your life while you are kept from bleeding to death and kept from having a respiratory arrest and what we call “pulseless electrical activity arrest from what isis essentially a overdose of powerful anesthetics. Futile life support is what you want to avoid

  53. Irubin, if the nurse didn’t ask for the pill you wouldn’t have seen the patient at all. The nurse still gets the credit you are trying to snatch away for yourself.

  54. As a nurse, I absolutely agree with you. Have seen my fellow RNs assessment skills really fall down on the job. You must do your own assessment. Family members are probably a better way to confirm a patient’s true baseline than the nurse who just met them that evening.

  55. Your grave mistake is giving in to the insistence that everything must be quantified in the first place. This "scientific" standard ignores human emotions, human experiences and human differences. And as "evidence-based" data have taken over human-based knowledge (even in mental health counseling), many patients have suffered. I finally convinced my primary care physician of 15 years that I'm not an algorithm. My care improved dramatically when he looked at me and listened to me instead of journal articles.

  56. My MDs are highly trained newbie GPs and their supervisors in the setting of a most prestigious teaching hospital. Over the years these professionals spend more time looking at the lab results than at me. My body is hardly ever touched, my movements and gait never reviewed - I have basically become the dehumanized sum of my lab readings. In this context nurses are the only ones who see patients as people and who pay attention to all aspects of a patient's condition: skin color, breathing, coherence, sleep patterns, and such. These are not gut feelings but conclusions based on years of experience and training. One would hope that medical teams would pay attention to these invaluable insights, even if they are not always quantifiable.

  57. I call it Cultivated Instinct. A good RN has it... but it takes time to develop.

  58. I agree wholeheartely and think the Rothman Index is crucial to good patient care, but just as important, I believe, is continuity of care, and in our local hospitals that is difficult to find. When my sister was recently hospitalized as a result of a hemorrhagic stroke and was in neuro ICU, she had only one nurse who saw her three days in a row; in the remaining 20 days in ICU she had 9 different nurses on day shift alone, and as a result, no one knew what her 'normal' was so were not aware of the minute changs that her family could see. I realize that staffing shifts is difficult, but I believe unless nurses monitor and get to know their patients, these minor danger signals will comtinue to go unnoticed and perhaps result in unnecessqry deaths.

  59. I learned early on that you listen to nurses. It took a while longer to appreciate listening to patients. “Gut feelings” aren’t gut feelings they are observations we make that we can’t quantify or adequately put into perspective. That certainly doesn’t mean they should be ignored. Instead, like everything else they must be put in context. The alternative is to ignore subtle observations until they fully declare themselves. We once talked about the art and science of medicine. The most brilliant physicians I have ever worked with were the artists and they had the best “gut”

  60. I would see the first case a little differently. A skilled nurse noticed a significant amd crucial change in the patient's mental status, a finding which will frequently not be reflected in changed vital signs or lab tests until too late. The medical team chose to ignore this critical observation because it was made by a nurse.

    Nurses' observations are critical patient care information. Unfortunately, in the electronic medical record they are very hard to find without a special effort by the doctors to review them. Placing nurses' notes in the same place as physicians' noted would make a difference.

    It sounds like the Rothman Index might help, but as long as doctors ignore nurses' observations due to lack of respect it won't help enough.

    Jack Kashtan MD, FACS

  61. Exactly, if you operate as a team and not a hierarchy then you provide the best care for patients. That means valuing all the team members experience, education and responsibilities on behalf of the most important person , the patient.
    The arrogance that it takes to think you have the most important role and voice is mind boggling. Nurses in hospitals are the primary care givers of patients, they know the drill and their patients. Listen to them as valuable members of the team

  62. I have been a nurse, an ER nurse, since 1995, I've been an ER ARNP since 1999.
    As someone firmly situated between the staff nurses and the Md's I am in a unique position to see both sides of the fence-so to speak.
    In my current ER practice, I find that all of the providers put great value on the nurses Gestalt, that sense that something is amiss, I'll even go as far as to say that we rely on the nurses to notify us that there has been a change in a patient's status. We have to, because oftentimes we are multitasking both the critically ill patient and the "my ear has been hurting for a month"
    I hesitant to say that another algorithm, another form-as helpful as it may seem-only keeps the nurses in front of the computer and away from the beside where they want to be, and where they belong.

  63. Like Mrs. Brown's feelings here, but it's hard to state if chemo earlier would have saved that acutely presenting patient. It's just too difficult to tell. As a physician, I wish pieces like this one would have used examples that were more clear cut. There often might 2-sides to the story and we didn't hear that of the "slow-moving" physicians. Even in the case of Mrs. Rothman itself -- it's hard to tell if the tamponade didn't happen later (after discharge), if it could have been prevented or even treated if caught in the hospital. As for the Rothman Index -- great - let's use it -- but, if it proves better than a nurse's gut in a head to head study. That being said, we should listen to caring nurses -- their extinct is hard earned and well honed. They are trying to care for the sick, just like physicians.

  64. @beskep (instinct)!

  65. My first child turned out to be in a double footling breech presentation. It wasn't my (excellent) obstetrician who determined that; it was the shift nurse who had concerns about the progress of my labor and suspected that something was amiss. She took it upon herself to get me to imaging to confirm her suspicions, at which time my obstetrician was called to perform an unscheduled Caesarean.

    My daughter was partly named for that nurse. And I will always be glad that I gave birth in a facility and era that could create a good outcome for an unforeseen double footling breech.

  66. Most hospitals now have a system in place to deal with minor changes in a patient that cause concern, or even to act on a nurse’s instinct or “gut feelings.” Nurses who notice subtle shifts in a patient’s vital signs or condition, or who just feel that “something “ is wrong, can call a “rapid response .” This alerts a special team including a doctor and usually an ICU nurse to come and evaluate the patient. Nurses are told not to worry that they might be wrong, but to call and let the Rapid Response team figure it out, with the hope being that patient deterioration can be caught earlier, before it becomes critical.

  67. @Bernadette
    In my experience rapid response teams are more geared to unstable clinical parameters, not sufficient to call a code, but certainly more overt than the findings in the cases described.

    The subtle changes noted fall back to the primary physician and other clinicians who follow the patient over the hospital course.

  68. Effective communication between clinicians with different observation vantages provide the care coordination that might make a difference in the types of cases reviewed in the article.

    Two continuing trends in present day acute care medicine make such communication less and less likely. The first is the EHR [electronic health record] as currently constituted. First of all the cutting and pasting and slotting in of results leads to bloated documentation which includes [often inaccurate] miscellany from throughout the hospital course and before in each progress note, making the small daily clinical shift essentially impossible to detect by review of the chart. Additionally the data entry screens of the nurse, doctor and every other clinician is different, and the printed chart is indecipherable to all because its formatting is even more arcane, so that each discipline is effectively more locked in isolation.

    The other factors which preclude doctors from paying attention to other clinicians is their training and reimbursement. Because the training remains hierarchical, young insecure physician trainees are commanding experienced nurses and other clinicians. To emotionally gird themselves, they become intolerant of criticism and input, and now communicate only by EHR. Finally the reimbursement and measurement of their "quality" is also only based on the care of the EHR not the patient. The system will only deteriorate if we allow current trends to continue.

  69. @TVCritic
    By "trainees" do you mean medical students, interns, residents and fellows?

  70. During the long declines of both my aunt and then my mother, I saw too much of the attitude that "something will get her soon" that seemed to stifle action.

    My mother rallied for another year and a half after we had "the meeting" with two doctors telling us to give up, that she very likely would never wake up.

    During that extra year and a half, her grandkids spent long days with her doing 24/7 care, not too demanding but needed for her to stay at home. They bonded. It seemed to be a real pleasure to all, and the kids grew and benefited in ways clear still. It was one of Mom's last great accomplishments that she listened to them so well, and was heard when she advised them.

    The doctors were wrong to counsel "do not revive" and to accept, giving up.

    Later one of the rehab nurses told her that, "we had given up on you." Mom was a bit shocked to hear that, and repeated it a lot.

    End of life comes, but it does not always come when expected, in either direction. We mustn't assume what we can't know.

  71. This is such a thoughtful and important post. I had to fight hard with hospital doctors who had only just met my mom, also family, who all bluntly told me that my mom didn’t have the RIGHT to decide if she could be given a chance to live. Not one doctor even asked the patient. So much easier to just let her die when it was (others) poor medical care that caused the emergency! They finally backed down and she was treated and then sent to rehab. She lived another 2 1/2 years. During that time, though frail and in a nursing home, she touched many lives for the better and resolved her life’s loose ends so when she did pass on, it was on her terms and peacefully. Treat the patient with dignity and listen to them, as you hope to be treated when your time comes around.

  72. The same thing happens to observant nurses as happens to observant doctors. We have gut feelings that something is not right, and some of the time we are correct. Observant nurses of course are the same, and can play a role in alerting everyone and beginning the diagnostic process to figure out what’s wrong. Who would argue otherwise? Is there someone out there (in real life, not a TV show) that doesn’t think that nurses can observe their patient and tell when something isn’t right?
    That is not to say that everyone’s hunch is correct, again the same with doctors, nurses, or anyone else that is around the patient. Lots of things turn out to be the opposite of our hunches, and staying open to that possibility also is prudent. Not every hunch is a catastrophe waiting to happen.
    I guess my overall reaction to the article is: of course all this is true. Therefore we remain vigilant, and consider all factors, and observations of everyone. So what is the point of the article?

  73. @Doctor The point of the article is that I'll bet very nearly every nurse out there can point to an instance where s/he brought a "gut feeling"-type concern to the medical team, they squinted at the numbers in their computers for a bit and decided nothing was wrong, and then the patient suffered a negative outcome related to the concern that was not acted upon. The point of the article is both to illustrate a tool that has been developed that highlights the value of quality clinical assessment, and to emphasize that it matters that the bedside nurse be able to catch and call attention to the minute changes in patient status that unfold over a 12-hour shift.

  74. @Doctor
    The point is, a nurse spends at least 200x's the amount of time with a hospitalized patient than a physician does. This article is not about a doctors hunch, it's about a nurses hunch. You can't always be vigilant on your own. That's what we are here for. Why do you feel the need to bring your own perspective in to everything. Ugh. Something tells me that you are the kind of "doctor " I dread having to talk to.

    Not everything is about you.

  75. Years ago, my sense that something wasn't right saved a child's life. This boy, a doctor's son, had been admitted with unexplained injuries (parental abuse suspected). I decided to check him just before I went to lunch, even though I'd done so a few moments before. Examination revealed that one of his pupils was largely dilated. The neurosurgeons took him right to the OR, and the boy did well following surgery.

    This happened in one of the best known children's hospitals in the US. When a clinician thinks something may be wrong, chances are that it is.

  76. Put a place in that Index for warnings from family members, too -- and from patients themselves.

  77. I am a physician and although the author seems to believe it is only nurses' notes that doctors ignore, in fact doctors also ignore other doctors' notes.
    When I do consultations on patients I always make sure that if there is a serious issue that needs to be addressed that I speak to the referring doctor or team as I know that they may often not even read my note.
    Similarly, I expect nurses to tell me and colleagues to talk to me about any problems they detect that they believe to be of significance in our patients as so much of what they are expected to put into their notes are routine things.
    Both these things take time from busy people but as lives depend upon us doing things right, it's worth doing them.

  78. NYT, you have failed me in a particularly annoying and, frankly, stupid, way that I do not expect. This is an article about the Rothman Index as a key tool for patient care. The Rothman tool is a graph.

    There is no illustration or photograph of a Rothman graph in this Opinion piece.

    What was the point of publishing this story without an example of this graph?

  79. @Jzzy55, I think most of us understand without it.

  80. I have been a nurse for 41 years. Nurses are responsible for so many autonomic system functions-- so subtle and yet so important separately and taken together-- balance, blood pressure, elimination, swallowing, energy, breathing, cough, mobility, appetite, color,motility in various systems, temperature regulation, plus mental attributes of memory, strength and coordination, hearing, vision, taste, orientation, mood, interaction, judgment, pain, planning, motivation,optimism, anxiety, sleep, attention, consciousness and so much more. When you have taken care of many patients, you come to notice the ones that are a little different from the usual or a little different from their usual. "Gut feeling" is not unscientific nor uneducated, but it is a way to enlist more help and mobilize more attention. I recall a young woman who arrived in our epilepsy clinic who just did not seem right in a difficult to describe way-- she was in absence status.
    The converse presentation of a gut feeling is also true in its power--when a nurse assesses that a person is doing better or is making tiny steps of progress. I think patients derive a great deal of comfort to sense from their nurse that what they are experiencing is not unusual, or can be managed and helped, or is showing a little improvement from earlier. My patients study my face as much as I study theirs. The communication of honesty, empathy, and unwavering attention takes the science of biology and transforms it into help.

  81. Beautifully expressed.

  82. I'm confused why a hospice patient was admitted to ICU instead of receiving comfort care.

  83. @Susan Lemagie. She may not have been a hospice patient but ultimately it is because this is America. There are $ to be made and no one has the guts to have the conversation required. I saw a patient last week who wanted to be worked up for lung cancer. He has end stage rheumatoid lung disease, nothing to indicate any further issue, and has a prognosis that wouldn’t be altered by addressing a cancer if he has one. Admittedly I may not be the most tactful person but ultimately the answer is “you’re gonna die.”

  84. @Susan Lemagie

    Thanks. Question I wanted to ask.

  85. Happens all the time. For lots of reason, not all of them bad, but certainly mostly bad reasons

  86. This op ed is a great wake up call because doctors, most regrettably, really are the weak link in health care. Their egos are so tied up in always being right that they'll far too often recoil from any suggestion that they may in fact be flat wrong in their initial diagnosis. And while it may be true there's a placebo effect to placing one's faith in the infallibility of doctors, one probably shouldn't indulge in such willful self deception without bearing it in mind that when it comes to cause of death malpractice and/or rank incompetence on the part of doctors is right up there with fatal road accidents and suicide. And in the case of the near elderly and the elderly doctors yield to no competition when it come to satisfying the grim reaper other than congenital heart disease, advanced dementia, and debilitating physical injuries of the kind that result from a serious fall.

  87. I spent 48 days in Acute Care at one of the great hospitals in Boston this past winter.
    The biggest thing I came away with was that the nurses are the backbone of the hospital. They know their patients better than anyone. I am alive and well today in large part due to their observant, astute , kind and yet firm care. They are the best.

  88. That was my experience as well at MD Anderson in Houston, Texas. I was there for over 100 days and I found the nurses to be knowledgeable, caring, compassionate, etc. I thank the universe every day for these professionals.

  89. I’ve practiced medicine in an acute hospital setting for over 40 years. If a patient’s family member or any of our staff, whether nurses or not, tells me that something seems off with a patient, I go talk to the patient and/or gather additional information. I value the input and experience of each of these individuals and also value the assistance we can get from technology such as the Rothman Index.

    Despite this I always find myself getting annoyed whenever I read This author’s columns. I don’t think I’ve ever seen her say something nice about physicians and it’s always easy to cherry pick experiences (like this) where ones instinct was right and someone else’s was wrong. I’ve had nurses be very astute but also had one call me frantically saying the patient was having a stroke. When I got there, after leapingbftom the on call room bunk, hitting my head on the ceiling and falling flat on the floor, the patient said he’d fallen asleep with his head on his hand and his hand went to sleep. I’ve also had times where my instincts (and direct written orders) were ignored by nursing staff with adverse outcomes as a result. Fortunately that has been rare, but it’s fairly common that nurse administrators refuse to allocate crucial staff and patients suffer.

    In the end, we’re all humans trying to do the best we can to help patients with the resources we have. The more we can use creative technology to help, the better!

  90. @NY MD

    I feel the same way about her columns and wish she’d channel her platform into a force for good rather than the same tired nonsense every single time.

  91. Great article. Really you are not only talking about having acute clinical skills but also acting as an advocate and activist for your patient. These are the keys to a great nurse in my estiimation and what I have always tried to do.

  92. Doctors, nurses, and health care aides have so many patients and so many charting responsibilities that it affects patient care. This is why it's so important that one family member stay at all times with the patient in the hospital. If the family member can see something is not right, and holler about it, a lot of people working in the hospital will get irritated. But, it may save the patient's life.

  93. @TH

    Exactly correct. A strong and ever-present presence with a family member can dramatically improve outcomes. If you help staff with care by comforting the patient, assisting with more menial tasks that do not require expertise and engage with everyone to be kept involved, the patient benefits. It always ok to ask what is happening, what medications are being given and where is the patient going and for what test. Learn the names of all support personnel. Be engaged. Not only will things turn out better, but you might learn something. Errors do occur, be nonjudgmental. Your presence is a major positive and you can help accelerate recovery.

  94. I learned early in residency to take nurses' concerns very seriously and I've never regretted pursuing a nurse's recommendation when they think a patient is looking sick. As a nurse or doctor or other provider your gut tells you a great deal and you should learn to trust it despite normal test results. In morning report it was hammered into us to judge how the patient "looks". It's a gut feeling that is honed by experience in medicine and with long acquaintance with a given patient, if you're lucky enough to have it. About the patient you say haunts you, while you haven't said much about her condition, preventing bleeding in the brain is usually not possible in the acute setting. I doubt very much that there was anything you could have done to prevent it.

  95. One problem with reading nursing notes is that the recorded thoughts of the nurse are very often buried in long sets of tables filled with numbers. It's often hard to find that meaningful narrative that a nurse records. One has only so much time when rounding. It would help if systems put the most meaningful information front and center and not bury it in the back

  96. @Dan Urbach This is a problem with the EMRs. Computers prefer quantifiable numbers and charts, and narrative is seen as less valuable. As you state, the nursing notes should be easy to access and readily available. EMRs are generally designed by IT people, and not by the health professionals who need to use them.

  97. This is a series of anecdotes. We are hearing about the times that this feeling was followed by deterioration in the patient's condition. It is certainly important that if a nurse feels that something is not right with her patient she convey that to other health care providers. What is not known is the denominator - how many times a nurse has this feeling and the patients condition remains unchanged.

  98. @Tom True, nurses can make mistakes. But the value of a nurse's experience is the ability to observe subtle signs and changes. I have also learned to listen when a family member says that something about the patient is different, and I never ignore that information. I would rather find that nothing has changed than miss something important.

  99. “Change in status . . .” Well-communicated to a doctor can make the difference between a great diagnosis and a terrible one.

  100. The same is true when family members have observations and concerns. Those who know the patient best and have experience with him or her, and who may well also listen more attentively to that person should be heard and heeded. Too often the professionals who come and go, with many things on their minds, or perhaps not respecting lay people, don't do that. And very bad outcomes can follow because of it.

  101. @jb or even the patient him/herself, may sense something is wrong and yet cannot communicate it or describe it.

  102. Yes! I was just thinking that! Sometimes the person least listened to is the greatest expert on the patient--the one lying in that bed.

  103. General impression is a better description than gut feeling. Much clinical accumen seems like it is not data based, but it is. It is the rapid evaluation and decision of signs and symptoms that experienced and talented medical professionals acquire as they work. It seems like a “feeling”. However, the clinical picture sets in motion rapid recall of past experiences that lead to a sense of the possible course of events for a patient. It is not hocus-pocus. It is real expertise telling you the possible and likely future course of events. It is based on what has been seen.

  104. Well said. Ms. Brown. I often tell my nursing students that people stay in the hospital because they need NURSING care. The instincts and observations of an experienced nurse are critical to the patient's welfare. We are the ones who spend 24/7 at the bedside. I am not trying to diss physicians...they are a critical part of the team. But just as I listen carefully to the physician, they need to listen to the nurse who is actually there, full-time, at the bedside. We are a team.

  105. While I agree with this article, in general, I echo some sentiments from other commenters. The first is that articulation, or communication, is key. The tagline of this article is “But I couldn’t articulate it”. Good communication is essential to patient care. The best nurses articulate their concerns promptly and clearly. Physicians with long patient lists are entirely dependent on nurses at bedside for changes in clinical status and for their assessment on how urgently evaluation is needed. I would argue the vast majority of doctors would not ignore a request for urgent evaluation. What really gets doctors is pager fatigue- a steady stream of pages regarding non urgent lab results or orders. Any concerns or changes should never solely be documented in a note, buried within piles on piles of notes I will never have time to dig through. Secondly, I want to emphasize that due to shift work, a given patient may have a different nurse every day- this lack of continuity is not given adequate mention in this article. Last, I am a young physician and already I am seeing those trainees younger than me spending even more of their day treating the screen rather than the patient. An additional “index” on the EMR is not the solution. We need to bring patient care back to the bedside and to do that, we need to free up time spent wallowing in superfluous documentation. A good first step would be streamlining and reducing EMR redundancies and having universal access to medical records.

  106. WOW!! What you said!

  107. Yes the EMR is a pathogen

  108. EMR is definitely a two edged sword. No 47 pounds of paper med records arriving on the unit along with the patient nor trying to read hand written H&Ps that are unreadable d/t poor penmanship...but it is true that healthcare has become fraught with useless data entry followed by useless cut and paste workarounds in order to get the actual work of caring for humans done.

  109. The author is correct about the difficulty of articulating such subtle cues as are noted by the bedside RN, as well as the wall that may be encountered when attempting to make oneself heard to the doc on call when, on paper, things may not look so bad. We are encouraged and required to supply EVIDENCE for our clinical opinions--and sometimes telling the doc,"She doesn't look right," just doesn't cut it. The Rothman Index can help, but so can a bit of practice in writing down and rehearsing ways to say such things in a calm, plausible manner: "The patient's affect & responsiveness to others has changed significantly over the last 12 hours. She appears almost obtunded, although her vitals have been stable and her labs haven't changed. I'd like you to have a look, please." The nurse/doctor relationship is now at its most collegial and professional than it has ever been before--and a good doc will listen & respond to the report of the bedside RN. We both have to do our parts to improve communication, use all the clinical tools available to us, and to allow ourselves the confidence to approach the MD with our opinion. Finally, I think it's incumbent upon experienced nurses to nurture and support the new nurses under our preceptorship and guidance, so that their communication & confidence flowers from the very beginning in rich soil.

  110. Family Doctor with 30 yrs experience here.
    What the RN describes in this article I like to refer to in practice as the "maternal instinct".
    Mothers will often say that something is just not right with their child too.
    The key is to communicate it directly verbally to the treating provider(eg not the medical assistant) , and be persistent, and trust your instinct.

  111. @CTMD
    So true

  112. @CTMD - What tips do you have for patient who does communicate directly to provider but is still ignored, belittled, discounted, whatever you want to call it? The arrogance of many doctors I've encountered over my years is beyond belief. Because they seem to feel threatened by patients who expect to be believed and treated as a human, I have come to believe these are the doctors who don't know what they are doing, and they are covering up by playing mind games with patients.

  113. Patricia Benner's excellent book "From Novice to Expert"- a classic when I was a young nurse ( possibly before the invention of paper)- articulately identifies the almost unique capabilities nurses have to detect, process and manage information that leads them to the same conclusions that this author is describing. It is a process of evolution for nurses, however. They don't graduate this way but there is something about how they accrue this information over time (becoming expert) that develops an analytical thought and action process, directing them to make some computer-like predictions about their patients which is different than acting on information in the present, such as in an emergency.
    Interestingly, pilots, professional poker players and money traders (if memory serves) are the other groups that share these spitfire analytical capabilities. Note that doctors are not included on that list. Family members bring a different and equally valuable perspective of knowing what's different. There's a role for everyone to play in the care of a patient.

  114. Family members can be a very important member of the care team—especially if they can articulate concerns in a way that helps medical team to be alert to things like (1) “Mom got really confused yesterday. She talked about seeing monsters and hearing voices and being afraid.” Team member: “Was she like that yesterday?” Or “Does that happen often?” “No.” Now the physician has good information to go with—sudden onset vs. gradual onset. This makes all the difference between a proper diagnosis of delirium (and proper treatment) and an improper diagnosis of dementia and improper treatment.

  115. @Marney Prouse

    Thank you. I have been thinking of this book since the first sentence of this article. I am a nurse-midwife and years ago wrote my dissertation using Benner's theory. I was trying to discern how faculty determined nurse-midwifery students were ready for "safe beginning practice." As soon as I saw "gut feeling", I thought Benner.

    I hope nursing students and faculty are still reading it.

  116. I believe in evidence-based medicine. However, it seems that the root problem here is not taking seriously the judgement ("gut feelings") of trained and experienced professionals.
    Somewhat analogously, the software industry is full of quantitative sorts who want experienced and expert opinions (about software quality, e.g.) converted to numbers before they will take them seriously, even though the act of shoehorning a valid gut feeling into a number is usually painful and often largely meaningless.

  117. What we need to be careful about here is that we all remember when we were right and everyone else was wrong, but we don't remember when we were wrong and everyone else was right. When a doctor responds to a nurses hunch that something is wrong but she doesn’t know what it is not only is he spending resources to try to figure out what she is sensing, which may be nothing, but he also can not be working on other patients where he may know what is wrong with them and is trying to fix it. I certainly don’t know what the correct balance

  118. A valid point, although it would be more compelling without the archaic gender roles of doctor = he, and nurse = she.

  119. Here in Canada more than half of all all medical graduates are female and we have lots of male nurses too. Not sure what your situation is, but imagine it is likely similar.

    Speaking as a physician, I take the hunches or bad feelings of nursing staff seriously, because there is no downside clinically and it contributes to heuristic learning. In our frequently over extended clinical settings, communication is critical and always at risk.

    Also, I’ve had those bad feelings too. I trust them as an invitation to pay closer attention. Sometimes when we work backwards from that ‘little warning bell’ and ask ourselves why something seems off we do identify objective findings that explain it. An otherwise well-looking baby boy with an unusually high heart rate who just seemed off (and who nurses actually weren’t worried about) turned out to have necrotizing fasciitis (flesh-eating disease). Moving him to the ICU before that became clear saved his life.

    A last thought about the idea of another logarithmic tool to broach the divide between nurse and doctor: it sounds like it may be worth trying. It would not be a substitute for communication and teamwork.

  120. This column makes no mention of the opposite problem: nurses who dismiss patients’ concerns and symptoms and rely on a different kind of “gut instinct” when they should be reporting those concerns to a doctor. Too much of medical treatment is handed over to nurses who overestimate their abilities. In my experience, the care described by this author is the exception when it comes to nurses.

  121. As a now-retired psych liaison clinical nurse specialist on the medical units of an academic medical center, I don't know how many times I worked with distressed nurses who were trying to get the doctor's attention for a patient whose status had changed.

    Although they mentioned "gut feellings" and I got it, that would not fly with the data-driven residents. So, we reframed it in words they could understand. So, Ms. Brown's feelings about her patient would best be dellivered exactly as she says: "[Dr, your patiend] ha(s) grown confused and her speech (is) garbled."

    According to Patricia Benner, author of "From novice to expert", the expert, having seen a particular situation many times, no longer relies on a list of characteristics to explain her/his assessment. In the end, nurses at the bedside are the ones who shape doctors' reality and learning to be bi-lingual is helpful.

    And if there is a trend toward what KA mentions, it has to do with nursing lowering its entrance to practice instead of raising it.

  122. Of course "well-honed clinical instincts matter". If "it’s hard to get a doctor to listen", then it seems to me a nurse should be able to access some type of urgent review process...

  123. The problem today is most everyone on the entire 'care' team really doesn't care. They're too busy or distracted or whatever, looking forward to their next break or end of shift. The doctors just wander around and look/act important after glancing at notes. None of these people are truly in charge nor know what the heck they're doing. Deep down we all know this. They're just practicing crisis management or reactionary medicine. The well being of the patients is of course secondary right after billing.

  124. @Lee As I lifelong healthy person who has recently encountered a serious condition which has involved hospitalizations and many, many doctors visits, I can tell you this is not true -- not even a little bit. Of course individuals' level of commitment, exhaustion, distraction varies. But as a group, they are people who are working very diligently for the health and wellbeing of their patients, sometimes at the cost of their own. They don't always know what is going on -- they can only surmise, based on what they observe -- but to say they don't care is wildly inaccurate and unfair.

  125. @Lee
    I once took care of a critically ill "neuro" patient on whom minute-by-minute intervention, observation, and in-room computer recording were required to track any subtle changes over time. This included Subjective as well as Objective observations, all critical in understanding the unfolding events. The arrogant young Resident approached me as I was diligently working and asked what had happened over the course of the shift and when I said that it was all detailed in the nurses notes that he should have read just before coming into the patient's room, he said, "You know we never read nurses' notes."

    I had everything I could do to keep from telling the arrogant little snot to go pound sand. And to please send in a doctor who actually cared about attending this patient.

  126. So gut feelings are really just a conglomeration of bits and pieces of objective facts pulled together into a hunch.

    This is why many hunches shouldn't be ignored.

    Disasters can be avoided by paying attention to hints from real behavior.

    Those who knew Tony Bourdain was a depressed individual who had talked about wanting to end it all and then behaved for several days in a down beat attitude could surmise that he was in danger.

    A direct intervention with him by asking if he was thinking about hurting himself might have averted his suicide and got him treatment. In actuality, he needed to be hospitalized with a suicide watch and antidepressive treatment until he was out of danger.

    This is a valuable lesson learned from losing Tony so tragically!

  127. Thanks for your article. It angers me that doctors refuse to act unless some unrealistic metric is met.

    I have nearly died several times due to this mentality and due to plain stupidity of doctors. If you think they don't pay attention to nursing staff, you should realize they don't seem to listen to patients either.

    Most recently I went to a new internal medicine doctor at a highly regarded university medical center, gave him my medical records, including a summary of surgeries, allergies, meds, current medical issues, and the like. When I logged on to my patient portal, I discovered that they did not post three conditions that could compromise my life should anyone there not be aware of them. (Two require daily medication.) This was deliberate, I am sure. A competing university medical center is handling one of them (as they are the country's leader for this particular problem), he had mocked the doctor who treated me for another one because he doesn't believe I have the condition (never mind that he never saw test results and has no working knowledge of it), and apparently he simply isn't familiar enough with the third one to even believe it's real versus something I conjured up. Just because something is uncommon doesn't mean that a patient doesn't have it!

  128. Nurses spend much more time with patients than doctors .
    Their gut feeling is the result of experience, not something born out of nowhere.

  129. It is the “nurses spend more time with patients” that makes the difference. Nurses have the opportunity to see sudden changes in status—what was a sharp patient, for example” become confused. It’s not enough to order the lab tests—someone has to read the results and look for important changes. A good assessment begins with a good answer to the question: “what happened (changed) and when did it change?”

  130. What is the "solid evidence that when a nurse says she’s got a bad feeling about a patient, the entire care team needs to listen"? Has the Rothman Index been validated and shown to be better than current practice? How exactly are nurses concerns quantified? And how much are the Rothman's charging for their tool?

  131. @Jeff I was wondering the same thing. I looked it up on Pubmed and there have been some studies showing that this index can predict who is at highest risk of ICU or or hospital re-admission. It uses a several data points from the electronic medical record. Many of these data points are part of the nursing physical assessment: bowel sounds, oral intake, incontinence, etc. as well as lab results and vital signs. So the tool makes a prediction based on quantitative data not a gut feeling.

  132. Now, let's look at the flip side: how many times did the nurse have a "nagging feeling" and it turned out to be nothing. My guess is that false "nagging feelings" occur far more often than positive ones. Despite popular belief, gut feelings are notoriously unreliable in the majority of decision making endeavors.

  133. @Francis
    I would rather a "nagging feeling " be fully explored and only then dismissed as "not much", than ignore it outright and be wrong, FrancIS (if you get my not-so-subtle hint.)

  134. @Francis , Since as another commenter mentioned, "the nagging feeling" is really the result of experience, it might be more accurate to term it intuitive ability, based on experience. I'm not sure that it has been or perhaps can be quantified, since most evidence is anecdotal. so is "notoriously unreliable" supported by studies?

  135. I retired from nursing after 45 years in various positions, lastly VP of Nursing for a nursing home management company.
    When I was in home care, more than 30 years ago, I went to see a patient who'd just been discharged. I cannot remember why she'd been in the hospital. However, this was my first visit ever with her. Her vital signs were all good but she kept telling me she "just didn't feel like herself." She said she was afraid and had no reason to be afraid. I called her doctor who gently said, "Send her to the ER." I did.
    The next day, when I was still in the office, I received a phone call from this doctor. "Well, Mitzi. I want to know when you're hanging out your shingle. Mrs.___ was having a silent heart attack."
    It's not just the nurses we should be listening to...

  136. @Mitzi Reinbold
    Your closing sentence is one that should always be respected. Ten years ago, I was being treated during an acute phase of ankylosing spondylitis by means of a sulfide medication. All of its side effects, some of them quite hair-raising, were explained away with "That's part of the symptoms." To make a long story short, I needed nearly two years of treatment to get my blood back to standard, and the ischemia caused by acute anaemia caused (fortunately) reversible brain damage. Only ten years until that was 'repaired'. And all that because that doctor refused to take my observations seriously.

  137. I could cite many similar episodes in my career. However, lets step back and look at the big picture: what provides such "gut feelings" is experience. Years of encountering patients and recognizing when something is not right. The experience of hands on care is being replaced by younger, far less experienced nurses who are directed more by technology than by face to face, hands on care. I started my career where specialists and nurses rounded together on the patients. Nurses were taught and mentored by those physicians. Now, time is money. Physicians don't have the time to spend teaching what they know. They used to do it because the nurses became their eyes and ears when they were not available. That model has changed. No more family doctors in the hospitals. Because of computerization, far more patients per nurse per shift. No one with whom the patient has any relationship. And the patient has no knowledge of whether the physician is good or not. The next step is right around the corner: a computer will be wheeled into the room. The doctor will be in a room nowhere near the patient and will conduct the examination and interview from a video screen. All the "necessary" data on an adjacent computer. And will rely on nurses with but a few years of experience. Perhaps what will be needed is the "MYGUTFEELING" app. Remember when you used to take manual blood pressures. Ah, the good old days.....

  138. Agree 100%. Doctors may swing by for a few minutes when you are hospitalized, but it is the nurses who can keep you alive. Doctors love their labs and their numbers, but few develop that INSTINCT based on years of close contact and observation that a good nurse develops. Subtle shifts, not yet discernible in tests, but clear to the nurse that a turn has been taken.

    When you are hospitalized -- pray for a good, competent, nurse. Your life may depend on it.

  139. @Atikin,

    I’m a retired OR and Home Health RN. I must disagree with your conclusion that only nurses keep patients alive. While nurses are at your bedside they are working closely in collaboration with physicians.

    Physicians most certainly develop and follow that “instinct” you only want to credit nurses with having. That “gut feeling” is not so much instinct as knowledge gleaned from experience.

    If you need a cardiac catheterization (heart cath) or surgery it will be a cardiologist or surgeon who’ll be doing the procedure, not a nurse. Hopefully you’ll value their years of experience and their “instincts” to get you through the procedure. As someone who had a heart cath I can tell you I’m thankful my cardiac interventionist was exceptionally skilled, got the catheter in on the first attempt with minimal discomfort, and made the entire experience more pleasant than I anticipated.

  140. Research shows, sorry citation not at hand, that delirium is misdiagnosed as dementia (or worse—psychosis particularly in Parkinson’s patients) by doctors 90% of the time, despite the fact that nursing notes showing an important change or changes in status—any of which could be a red flag for a proper diagnosis are not read by the doctors. This often leads to improper prescription of medications and often leads to death. Dehydration or an infection is common in the elderly and causes delirium. Hydration, hospitalization, dim lights, and an antibiotic for an infection would resolve those cases. Another primary problem is the failure to evaluate medication interactions leading to delirium and often to death. I once heard a hospitalist say: “I have a patient who is going sour.” To me that meant that there was an electrolyte derangement that, had it been caught early enough, the patient would have lived. Jeanne Hannah

  141. Working as a physician beside nurses in my career, I could see their dedication and their skill. I had my own opportunities to see the green shoots of emerging trouble just breaking through the crust of the patients whom I was entrusted to care. Often a nurse might nudge these thoughts upon me and I was smart enough to recognize their contributions and act on them.

    We are dangerously straying from the art of medicine at the bedside into an over reliance on technology. Even the codification of the Rothman index itself depreciates insight while suggesting it can highlight it. Just because a tumor is below the detection size of current technology does not mean it does not exist.

    I remember a discussion between a colleague and his newly minted residents-in-training.

    Residents: We have a problem with a patient.
    Teacher: What's wrong with her?
    Residents: She has abdominal pain and she is too obese to fit into the scanner.
    Teacher: Have you examined the patient?

    In our professional lives, we all will face limitations in what we can bring to the bedside. The test is not available at this hospital. The patient cannot afford the test. The insurance company will not pay for it. The patient refuses the offered test. And on and on...

    Pushing the envelope of clinical skill is equally if not more important than pushing the button of the latest instrument or device if our desire truly is helping patients.

  142. @Douglas McNeill
    Finally the Art of Nursing and the Art of Medicine known as the Laying On Of Hands at the bed side. The importance of the physical examination cannot be over emphasized. I practiced for many years as a Visiting/Homecare nurse where we did not have all the bells and whistles as the hospital based professionals did. Many times it was my call to the doctor with the results of my examination of our patient and review of medications that resulted in immediate changes to the care plan keeping the patient on course or sending them to the ER. Our educated judgements were always respected and welcomed.

  143. Most of the doctors I know do listen to nurses, and why wouldn’t we? We know just as well as others that nurses spend more time with our patients than we do. And we have gut feelings that need to be reckoned with, too.

    This is a complex topic that lends itself to oversimplification, but my advice, particularly for young physicians, is to do what the nurses tell you to do. This means you should always ask their opinions. It will keep you out of a lot of trouble.

  144. @Franz Reichsman
    I would not follow your advice at all. One should never, ever just do what the nurses tell you to do. Patient care requires a team approach. Getting input and information from nurses, and coming up with a care plan together is not remotely the same as doing what they told you to do. Doing what they told you to do is no better than ignoring them.

  145. My daughter just started her second year as a nurse in the cardiac care unit of a major university hospital. Because all of the patients are in critical care, she is legally not supposed to be caring for more than 2 patients per shift (although that is regularly violated). She has authority to do things like titrate nitroglycerin doses by herself. A bad calculation can kill the patient. She is meticulous and regularly picks up minor changes in condition which she reports up the line because she realizes that these minor changes can portend bigger problems. For the most part, her observations are taken seriously and acted appropriately upon even if the answer is that the higher ups will simply monitor the patient more closely. Often the families point out issues that they think might be critical. The nurses have the ability and authority to bring these issues to the treatment team which is another way in which having more eyes on the patient can be very useful in restoring the patient to health.

  146. An acute change in mental status and garbled speech have absolutely nothing to do with "gut feelings". They are ominous symptoms of a stroke and or intracranial hemmhorage. Also, these are hospice patients, meaning that they have agreed to forego any type of aggressive treatment.

  147. Thank you for this piece. As a care provider, I have certainly had this kind of experience as well as the regret when I a bad outcome might have been prevented if I had only acted on impressions I had before the event. I'm especially enthusiastic about the index that includes these impressions in a read out of risk. This has the potential to save lives but also offers an opportunity to evaluate the impact of a human tendency to attend to only two of four critical pieces of evidence: 1) gut alarm goes off and something bad happens; 2) gut alarm doesn't go off and all is well. What we tend to ignore are: 3) gut alarm goes off and nothing bad happens: 4) gut alarm doesn't go off and something bad happens. Only by calculating the full range of evidence - as the index described would - can we judge accurately if these gut feelings are truly adding predictive value. I would be fairly certain that there are some cases that a gut reaction, taken seriously, would save a life but I'm less certain that its a reliable value for a large number of cases with varied outcomes. Glad someone will examine this.

  148. First, we need a health system whose engine doesn't run on money but the actual caring for patients. Yes, we have all this incredible technology but that shouldn't negate the importance of intuition. After all, it's our own intuition or that of a parent who feels something just isn't right, that gets us to a hospital or a doctor in the first place. Alas, health care now operates on the business mandate of time is money with little or no time for team consultation let alone intuition. Like a restaurant, they want to get you and get you out and turn that table over if their going to make money.

  149. It takes quite a few years for nurses to develop these “gut feelings”. Unfortunately, hospitals hire many young nurses to save their bottom line & don’t reward bedside nurses for stAying @ the bedside. Many of us don’t want to go into administration or management but it seems it’s the only way to make more money. 8 hour shifts should also be available to the older nurse who wants to stay @ the bedside.
    Patrice Katsanevakis, RN

  150. I am so grateful, as a nurse of many years, to see this article. I have a story that involves phone triage, a child who as a teen seems just too ill to have simple gastro enteritis and when brought in was found to have meningitis. He survived. Something kept me on the phone with that parent long enough to sense the urgency. The physician I worked with understood and valued my judgement. I was supremely lucky there. That was over 20 years ago and I do strictly telephone triage where critical thinking and the nurse's 'sixth sense' is highly valuable. But it is still questioned frequently by providers. I have not seen this index or used it, but if it can really quantify what goes on in my head it is invaluable.


  151. When my husband was hospitalized for 10 days for pancreatitis, he had the same nursing team in the AM and PM. These wonderful, compassionate, alert and observant women and men spent quality time every day with my husband. Their unique position afforded them to evaluate his symptoms, overall health concerns and ascertain if anything was amiss. My husband’s doctor was extremely skilled, capable and knowledgeable but it’s the observant nurses who had been medically eyeballing my husband for days. They would be the first responder to catch anything that began to go sideways.

    Somehow, if a nurse tried to explain to my husband or myself that she/he was making a determination about something based on her/his particular “agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment” we would have stopped listening right then and there. Perhaps in many cases “gut feelings,” actually aren’t feelings at all but most patients and their family members understand, recognize and have experienced “gut feelings”.

    While I truly appreciate and respect the logic and justification for the differentiation of the term “gut feelings” in this article, I’m going to stick with my own “gut feeling” and trust the nurses whom I would encounter on a daily basis should I ever end up in the hospital. They see everything, every day. The doctor merely gets the highlights and “cliff note” version of my condition once a day, if that.

  152. @Marge Keller. as an ICU RN of 42 years, I've experienced the gut feeling many times. You are correct that it's years of training, education & experience that just tells you that "something is wrong" even though everything on paper says differently.
    I called a new surgeon one night saying his patient's vital signs & lab work were all normal, but I just had a gut feeling something was wrong. He told me he'd be right in because his mom was a nurse & always said to run to your patient whenever a nurse called you with a gut feeling. The patient crashed quickly after he arrived & we were able to save her.
    Many other examples throughout the years.

  153. I recently had the opposite experience. All the years of nursing experience told the nurses that my induction would take many many hours - even a day. I went from pretty easy contractions to fully dilated extremely rapidly, and when the nurses came in and asked my pain level, I said "8? 9?" The nurse said "or maybe 5? Don't forget how much farther you have to go!" I gave birth about 30 minutes later. As they wheeled me to recovery, the nurse said "if you do this again, make sure to tell the nurses how this all happened." I HAD told the nurses that my mom had me and my sister in both about an hour of labor...I don't know what else i could have said (how about "my pain is level 9"?!). Anyway, I think sometimes experience and gut feeling works against outliers.

  154. Our health system is so strongly based upon profit and money that my first thought after reading this is that it is just a commercial for the Rothman Index product.

    Why we grasp onto our current health system so tightly when other countries public systems show us the way to a better quality of life is beyond me. Having a truly public health system geared towards care and outcomes rather than bottom lines would go a long way in curing me of my excessive cynicism towards essays like this.

  155. So many key takeaways from this story:
    - Nurse's gut feelings rather than "intuition"
    - that the people who spend time with a patient have an insight that a couple of minutes a day can't equal
    - that EMRs shouldn't just be complicated spreadsheet-like lists of data, but the data can be analyzed to spot potential trends. The time entering into an EMR shouldn't be thought of as time away from the patient, but as feed a data rich view of the patient over time.

  156. Agree. As a retired pediatrician with 40 years under my belt, I decided that numerical coding of clinical illnesses and symptoms, in the interest of billing, was the beginning of a dumbing-down of the clinical process, culminating in the wretched EMR systems that have turned providers into data-entry clerks, and which have nothing to do with patient care nor useful record keeping. I suspect that these systems were designed by the same folks who create furniture kit assembly instructions.

  157. When I was in nursing school, and during my early years at the bedside, we called this "nursing judgment". It was widely respected and accepted by both doctors and nurses, and may have saved many lives. No longer. If it cannot be quantified by a clinical value or imaging study no one accepts or appreciates it. Tbere are many reasons, including nurses spending less time at the bedside and more on documentation to satisfy clinical reviewers. But fundamentally it is a loss to good clinical care and militates against the professionalization of what we do as nurses. All the degrees and certifications in the world won't teach or replace nursing judgment, and that is everyone's loss.

  158. As nurses become “ expert in their field”......this intuitive sense we develop is extremely useful in our practice.
    This isn’t science ; it is experiential intuition.

  159. @Nurse Jacki
    And experiental intuition is the sum total of remembered data from prior clinical encounters.

    It is of high value when the intuiter is an inquisitive, analytic clinician who reviews clinical events and catalogs them in an logically sound and etiologically consistent manner - for such a clinician it is science, though not rigorously complete.

    Often, we see the intuiter who is uninterested and has developed route thinking. Such a clinician "knows" that the patient has such-and-such diagnosis without corroboration or consideration of the differential diagnosis. The results are not pretty.

  160. Spot on Theresa. Thank you for putting your nursing and narrative expertise together. Again!

  161. Well come on now. Let's have perspective. Example one was a patient with blood cancer admitted to hospice. The other was an 87-year old.

    You are a hospice nurse. People die. We need to be careful not to create an overwrought culture that lives do not end. They end. Sure you might make it a few days longer, a week, or even a month. But at what quality? What is the need to prolong it? Who does it serve? Quantity over quality is not always the best goal. "wondered if their mother’s death could have been avoided" - she was 87. The answer is "yes", but actually it's "no", no it wasn't. She was 87, and that is always close to death. We Americans need to accept death as a thing and stop trying to imagine we are immortal. People die.

  162. All other things being equal, the older you are, the closer to death. However, our mother was in good health, except for a leaky heart valve. One of the modern miracles of today’s medicine is that you can pop a new valve in, in what is a very low risk procedure. After the operation she felt great. She might have lived another 10 years.

    I do agree that people have unrealistic expectations with regard to modern medicine. People die. But this was an avoidable death.

  163. I am a retired Nurse, and I have had the same intuition about patients slowly getting sicker without vital sign changes. Slight mental status changes etc. Many were not older. When we would discuss it together as a team, we would often agree that something was not just right. When we could convince the Medical and Surgical teams to take a closer look, we often averted disasters for our patients. When you spend 12 hours a day with your patients, you really get to know them and their baseline health at those moments. The bedside is where you assess and know your patients. Hospitals need to have appropriate nurse/patient ratios.

  164. Matthew in NJ: the examples herein enabled people to walk back out into active, connected lives. The situation with hospice is one that merits careful consideration, but the point here was not necessarily end of life care. You make an important point, but these situations address this who can and do want to walk out.

  165. Skilled and experienced ICU Nurses are the reason I didn‘t kill anyone in my Intern year. They offered guidance and limitless patience with us „Baby Docs“. Can‘t thank them enough. I still bring cookies.

  166. When it comes to medical care, 'gut' feelings should always be ignored in favor of medical tests and diagnostic readouts. You might as well toss out the thermometer and diagnose a fever based solely on a hand to the forehead!

    Doctors go through rigorous training, years of medical school, years of residency, and years of diagnosing patients based on hard data. Nurses should stick to their guns and do what they've been trained to do: listen to the doctor, and care for the patient's basic needs. Leave the diagnosing for the people who have been trained to do it.

  167. @Michael
    This is why I object so strongly to the phrase "gut feelings." We need to recognize when we are observing subtle but real changes in a patient's condition and articulate them clearly. "Gut feelings" play no part -- careful observation does.

  168. @ Michael...just got out of medical school this spring? I can put my hand on a patient with a diagnosis of SIRS and tell you whether they need a ICU transfer no matter what the numbers show or don’t show. I can also
    Predict, like most experienced ICU nurses, with near certainty who will survive and return to a quality life and who will never leave the hospital. I’ve generally made that prediction just prior to you telling the patient’s family that “ things are looking better today, the FI02 is down the 80%;I think we should continue the blood pressure medications and the CRRT for a few more days.”

  169. @Michael
    As a mother I held my children daily for years,I knew what their normal body temp felt like. I always double checked suspiciously warm foreheads by putting my hand on their back or stomach. The thermometer was used to get a number for the Dr's office, not to tell me if the child had a fever.

    And the most valuable staff member at the pediatrician's office was the nurse. So much practical wisdom!!

  170. As a retired physician I applaud you for your astute observation. Both my father in law and my mother died of medical malpractice. My mother in the hospital in which she delivered me in Canton, Ohio and my father in law in Pineville, NC. Both deaths were due to medical personnel dismissing my gut feelings and that of nurses to whom I voiced those feelings. My father in law on blood thinners, fell after a TIA and sustained a head injury. I knew from his elevated blood pressure, somnolence and decreasing sensorium he had the intracranial expanding bleed that killed him. My mother with Lewy Body dementia was given Haldol, despite the fact that I told the intensivist as did her nurse, that it was contraindicated and she as the books will tell you died of a massive hypertensive intracranial bleed.

    In this era of speed and greed medicine, few arrogant God complex docs listen to the nurse or even physician family members. The QA committees of both hospitals concluded that since both family members were over 85 that their lives did not matter ( direct quote) and that their quick deaths were merciful! Until this arrogance stops and the old do matter, nothing we say will sadly accomplish anything and research shows that once no one is looking over their shoulders medical personnel revert to old bad habits. Good try to point out a cure, but sadly staying out of a hospital in America is the safest thing for all.

  171. 87 year old heart valve replacement? Good god our expectations are insane. What kind graphic can change that fact? That being said good nurses are amazing people, absolutely amazing. There just aren’t enough of them.

  172. @hbit It doesn't matter how old you are! You deserve the best care possible EVERY TIME unless you specifically say you don't want it. Your comment is an example of ageism at it's worst.

  173. One should have whatever one thinks one should have, but doctors ( and surgeons and oncologists in particular) have a duty to fully describe benefit vs risk, but also what to reasonably expect as an outcome in terms of quality Of life. An 85 year old who gets his or her chest cracked for a bypass or thoracic aortic aneurysms repair is quite likely to survive it today, but also quite likely to wake up with a delirium they will never fully recover from. I’ve seen that sort of surgically driven cognitive decline waaay too many times.

  174. Overall agree with article. But it’s a gross oversimplification. Also, I know plenty of nurses that do speak up. It’s called a professional. Lastly, I’m suspicious of this nurses attitude. It’s kind of a “ the medical community is evil and I the Nurse was the savior” mentality. Often medical people with this attitude ironically do not work well with others.

  175. @Primary care doctor
    MDs have ego problems that get in the way far more than nurses behavior.

  176. @ primary: while I don’t really know what it’s like to be a doctor I can tell you what it feels like to witness multiple “failure to rescue” situations ( what we’re actually talking about) as a RN. it always seems like the doctors have a much easier time shrugging off preventable deaths than nurses do. Every one steals a little (or a big) part of a nurse’s soul. Nurses are a patient’s last defense against a cruel and pitiless health care INDUSTRY. I’d rather be wrong or come off divisive than be unable to save a save-able life of someone I may have even formed a modest therapeutic relationship...

  177. Anything that will improve medical care by anybody is positive.

    The patient should always be the concern and not the caretaker's ego, be it nurse, doctor or whatever. Machinery has no ego, but the people who run it and interpret data do.

    Alas the human caretakers are just that: humans and everybody makes mistakes and screws up for more reasons than can be counted.

  178. While I fully agree that close observation and communication can be as important as lab results and vital signs, I just want to point out the greater value of the latter over the former.

    In recent years, I have been hospitalized twice, once in allergic shock, and once with sepsis. Each time, a doctor has commented that I looked and mentated much better than my lab results and vital signs would have predicted.

  179. Nurses do incredible work.

  180. @DallasGriffin
    Thank you from an RN.

  181. Any physician who ignores or, worse, denigrates a nurse for phoning because a patient “just doesn’t seem right”, is a fool.

  182. Nurses I work with can call 100 out of 3 close catastrophes.

  183. Not saving any lives, but prolonging deaths.

  184. @Generallissimo Francisco Franco

    Who are you to decide what is best?

  185. As bob Dylan famously said: “ he is isn’t busy being born is busy dying.” Too many Americans die either kicking and screaming or while so incapacitated that the families are the ones kicking and screaming. It is not up to the caregiver to decide but there have been scoring systems that consider quality of life, the likely outcomes of procedures on quality of life but also on longevity. An example would be Gretchen Schwarze’s tool for judging whether more complex peripheral vascular surgical procedures are worth submitting to.

  186. So many defensive doctors here.

  187. Another term for “Gut Feelings” is “pattern recognition:” The patient is somehow not fitting an expected pattern. Something is wrong. Identifying abnormal patterns, analyzing them, discerning their significance; obtaining additional information if needed is the fundamental skill of clinical medicine. Information from disparate sources has to be pulled together quickly to do this task.

    The recent introduction of the electronic health record (EHR), instead of making this task easier, has created information silos that impedes information gathering and analyzing patterns from disparate data types.

    The most obvious problem is that healthcare providers now type into a computer instead of talking to each other. Questions are not asked and abnormal patterns are not recognized.

    Important observations are buried inside mountains of boilerplate text that is segregated into different sections that are clumsy to navigate making comparison and pattern recognition much more difficult. To even look at vital signs, you have to log into a computer and click past 3 or 4 menus and then scroll through columns of poorly labeled numbers in order to identify an abnormal pattern. It is usually impossible to look at and scan through vital signs, lab reports, imaging reports, nurses notes simultaneously. You can only look at one data type at a time.

    The regulatory and bureaucratic burden now imposed on healthcare is overwhealming+absurd. We don’t need Rothman indices. We need simplification!

  188. @ Stasiak: thank you, yes!

  189. @J. T. Stasiak well put!

  190. I am in awe that the Rothman sons channelled their grief into developing this tool. They could have looked for who to blame or sued the hospital. Instead, they honored their mother by trying to prevent this from happening to other mothers. Bless you Rothman sons, your mother is very proud.

  191. @Redsoxshel
    Yes their involvement is inspiring.

    However, the use of a "multifactorial" tool becomes a blunt force instrument which will lead to other missed diagnoses because the patient did not meet the Rothman criteria and therefore were not thought to warrant more investigation.

    Like The fall risk assessments, the skin breakdown indices, the risk assessments for delirium, etc., the medical record will be replete with derived data of specificity and sensitivity which varies depending on the characteristics of the presenting patient, and when used on all comers will lead to misclassification. Which the malpractice lawyers will utilize to further dilute the effectiveness of each health care dollar spent.

  192. @Redsoxshel The Rothman index is a commercial venture. The Rothman sons license their proprietary software to hospitals. The cost to a hospital can be as much as $500,000 per year.

  193. I experienced my first so called stint in a hospital for 5 days. All in all, can't complain about the care, and diagnosis. I did come away with some observations of todays medical procedures. Doctors order the drug regime and frequency, and in my case of drawing blood going to the lab . Am sure this all gets plugged in a database . The circumstance that popped up was, nurses as expected are on shifts, handing off care to their replacements. A doctor only comes by once a day, and I had no way of knowing, with how busy doctors are, if through the course of a twenty four hour period, he or she, has time to look at data plugged in, or blood work results. A doctor on my floor probably saw 20 patients during the rounds.

  194. I could have written this based on my experience but I learned to collect the data an present it as objective not subjective information. Unfortunately I experienced the doubt and irritation on the other end of the phone. I also learned to document clearly when "the team" did not respond appropriately and have seen these cases reviewed in peer review. Nurses, make yourself a credible communicator.

  195. This is not about nursing, but intuition. I used to drive into NYC at least weekly. Occasionally the idea would pop into my head to try a different, sometimes unknown route, which I always disregarded until I realized that when I did ignore the idea, I ran into traffic problems that made me late. I decided to start paying attention to my intuition and was never late again. Since then I have paid close attention to my intuition, and it has never steered me wrong. Those who discount intuition are depriving themselves of one of our most powerful ways to understand our world and how it works. There are many kinds of knowing, and scientific knowledge, while valuable, is quite limited. When we recognize that we are much more than merely rational beings and that our conscious understanding of how the universe works is partial at best, we may be able to begin to realize our full potential.

  196. @J Shanner
    Please understand that this is NOT about intuition, and I object strongly to the term "gut feelings." I have been an RN for nearly 50 years, and my most important professional skill is observation. Just by shaking someone's hand I know something about their circulation based on skin temperature, state of hydration if their skin is a bit dry, muscle tone, range of joint motion, presence/absence of a tremor, and more. With continued observation I can notice subtle but real changes that may indicate something significant.

    Fortunately for me and my patients, I have worked most of my career with other health care providers, including MDs, who trust and value my observations. Too many providers now days rely too much on "the numbers." Physical examination and clinical observation are becoming lost skills -- to the detriment of patient car3e.

  197. @ shanner: no this is about Nursing. No one does when you’re late to work. Your thoughts would be more valid if you were a professional traffic engineer who followed his or her “ intuition”

  198. As a MD, I try my best to always listen to my nursing staff. They are usually on to something I might not yet realize.

    I am much more skeptical of tools like the Rothman Index. Many of these tools only see to increase cost of care without much benefit - like obsessing over patients with mild bumps in their lactic acid because the might be septic or thinking that every patient who meets SIRS criteria is nearing death.

  199. About time. Nurses have a much better sense of a patient's condition than the doctors, who see the patient maybe once or twice a day, and must rely on pieces of paper and numbers on a monitor.

    Now let's pay attention to family members gut feeling. They often have an even better sense of a person's condition. Small shifts in behaviour, not enough to trigger clinical concern, are too often early warning signs.

  200. My understanding of rules for admission to hospice require the patient to be within a short time of death. The nurse’s instinct would have prolonged that period & perhaps increased discomfort for a dying person.
    My niece, who lives in England & was born in France, once said, “ Americans believe that dying is an option”.

  201. Hospice care generally does not require the patient to be in extremis or even likely to die within the year. It can simply require a change in care from cure to paliation. Interestingly this change in the goals of care result in prolonged life.

  202. Part of the problem is that the American health care system is more of an assembly line than it is care. Hospitals cut back on skilled staff that deal with patients. The tech who takes the blood from a patient isn't going to know if something is going wrong. The nurse who is busy doing paperwork may not have the time to look in on a patient more than once a shift. And the doctor, who is in charge of the whole deal, definitely isn't looking at the patient more than once a day.

    Our hospitals are like factories. The care is impersonal. Patients are complained about if they expect too much or require too much. Rather than being run for patients, hospitals, like our entire health/wealth care system are run for profit and convenience. That doesn't leave much room for inefficient care where patients are listened to and cared about.

  203. After 20 years working in health care as a P.T., I am convinced that the floor nurses are more in touch with the patients under their care than the physicians who are in charge of treatment. I hope that physicians would give more weight to nurses' observations.

  204. @Joan Erlanger
    You are absolutely correct. As a physician (internal medicine) I may have up to 20 patients under my care and a floor nurse generally has no more than 6. She spends hours with her patients and I breeze in for a few minutes in the morning and unless something changes I may not see them until the next day. I need the feedback and reports of the floor nurses and PT's and ayon else on the team to help me care for the patient.

  205. 6 is 2 too many with today’s complex “general care” patients, but then that would cut into profits which are the prime driver of the medical industry in America.

  206. Health care is a science, but it is also an art, which benefits from strong intuition, based on experience. I have used my intuition all my life, and it has served me very well.

  207. This is an example of the shortfalls of technology and lab ranges, many of which are faulty. Clinical impression and judgement, along with the experience of the clinician, matters most when it comes to the health and vitality of the patient.

  208. Thank you for putting patients' well-being first.
    In addition to listening to the nurses, Doctors should also listen to patients' loved ones.
    At the end of my father's life, he was hospitalized after having severely low blood sodium. Those numbers improved somewhat with treatment, but other problems soon developed. My father made incoherent and hallucinatory remarks. Breathing was difficult. He was deappetized. But the Doctors were stuck completely on his one improving sign and moved him from the ICU to a regular room, where he received nominal attention. We pleaded with a Doctor who had been treating Dad not to move him away from the stronger care structure and were told, dismissively, that it was a team decision.
    My father died less than three days after being moved. We have some peace because he was late in life when that happened. But that won't be true of everyone. Families know when something is amiss. We may not have medical titles, but we should be listened to when we describe our gut feelings.

  209. These are multinomial probability distributions. A nurse is making simultaneous assessments of multiple factors in real time and is therefore gaining more information than measuring a single factor like heart rate or blood pressure. Humans are very good at assessing complex situations real time. As a Process Engineer I saw the same effect occur repeatably over 30 years. I would really love to see how these Engineers created their solution.

  210. I have been a nurse for 34 years in both acute care and academia. I was lucky to work in several facilities where the nurses' judgments and intuition were trusted by the physicians, and we were given latitude to order tests and to ask the docs to see a patient STAT. One was a small community hospital ER, the other an ER at a big city ER, and the other a medical clinic for the homeless. As an instructor, I saw the decline in the ability of new nurses and students to even have an opportunity to develop the assessment skills and time to spend with patients to develop intuitive skills. Time is spent documenting a "head to head" assessment and clicking check, check, check. They spent their time administering medications and looking at monitoring equipment rather than at the patient. At the same time, experienced nurses are retiring -- those that I learned from as a new grad. Many new nurses leave the profession within 5 years, disillusioned with the reality of nursing in acute care settings.

  211. As a physician/patient, I was appalled to experience the New medical efficiencies: no MD took my history- that was relegated to nurse practitioners, no bedside RN was assigned to my hospital care for more than one shift, vital signs were methodically charted by aides, labs were automatically drawn at 5am- but only the electronic health record held any continuity of 'observation' as the MDs, fellows, residents, nurse practitioners and physicians assistants dropped by - in a parade of fragmented care. The opportunity to enhance clinical awareness that is crucial for complex acute conditions was lost as no one saw me over time- seeing me well vs failing.
    Yes the Rothman Index is useful, but a structural change would help as well: promote continuity of clinical management. Assign RNs to a patient for the duration of the hospital stay. (In some hospitals, hospitalists replace tiers of trainees and can also provide a longer term view.)
    It is appalling to see the computer record undermine sound clinical skills and watch MDs, usually swamped and goaded by administrations to worry about the profit margin, aim for quick discharge as though that was the new gold standard of professional competence.

  212. As of five years ago when I retired, electronic nursing records are making this situation much worse! They should have improved our process, since they offer the possibility of analyzing trends and setting criteria, but the ones I've seen don't come close.

  213. @Dottie Davis I agree. It seems to me the purpose of electronic notes is to shield hospitals and physicians from nurses articulating deviations from plan of care. The automated notes make it difficult for the nurse to note anything different that may have happened. I participated in an adverse events study and institutions that had automated notes had no place where nurses could note what really happened

  214. @Dottie Davis
    Agreed. The more "high tech" we get, the more alert we need to be. As a long term burn nurse I have had to teach many new nurses that we nurse the patient, not the machine. Just because an alarm is not going off, that doesn't mean that everything is fine.

  215. problem is the age-old idea that (to quote something I don't believe in) "The nurse is handmaiden to the doctor". Nope: not true, if indeed it ever was. Smart docs know that the RN or LVN is your most sensitive patient monitor, and best pay attention to him or her as well as, if not more than, the various 'scopes and 'ometers. And I think most of the time that's the way it is. It's about teamwork, folks; and regrettably, some of us docs aren't good team players.

  216. @G Ingraham MD
    Sure Doc, team playing is key but i want to pick my team players, to make sure they follow my decisions diligently and do not delay or suggest a second or third opinion or having this people on board, etc, etc

  217. My granddaddy was in the hospital, in bed but waiting to go home that day after a minor procedure. The family was visiting that morning, talking and cheerful in that somewhat hyper hospital-room way. Some were leaving on a trip, some were making plans for later that day, a nurse was coming and going at the time. And Granddaddy said softly that his arm hurt. No one seemed to hear in the noise going on. I was right by him, and I heard. I repeated, "He says his arm hurts." But no one heard me. As the nurse leaned over him, I said it again. It was strange, but no one paid any attention at all. And I let it go, and Granddaddy let it go. I guess you can figure out the rest. The call came that afternoon, just as we were expecting to hear he was back at home. A massive heart attack, and he was gone. Years later, I learned that pain in the left arm is a precursor of heart attacks in men, and well, it was a hard thing. Even now, old myself, I feel guilty sometimes for not making more noise, not yelling or whatever I could do. But this is true, and I've seen it since: people pay least attention often to the very person who knows the patient best, and that's the patient himself or herself. In that role, you seem to become invalid, I mean not valid, anymore. We need to guard against that, all of us. That person is valid, and should be heard and responded to with respect.

  218. @jb I’m so sorry you had this experience. I’m an intelligent woman who is good at noticing and does not “awfulize.” I cant tell you how many times my valid observations have been dismissed. Or that I’ve been offered a prescription for antidepressants for what turned out to be an actual physical issue (it just took a more in-depth look — often one that I had to initiate myself). It’s no wonder so many of us try to steer clear of mainstream medicine any more. Dismissiveness is epidemic!

  219. Nurse here, 40 yrs of practice in multiple settings. What a "gut" feeling is actually the knowledge and experience to note subtle changes in a pts condition. Skin color, resp rate, lung and heart sounds, mental status...all the little things that go into assessing the whole pt. This includes listening to what the pt says about how they feel and what family say. I learned how to do this in nursing school 40 yrs ago. Part is science, part is the art of any healing profession. Ignore a good nurse at your peril, for sure.

  220. Amen to that (doc with 40 years of experience).

  221. With all due respect to nurses, are we referring to perception bias here?

    While there is little dispute about mother’s instincts, or perhaps in this case there should be little dispute about nurse’s instincts, is this essay really a commentary about a lack of respect felt by nurses from some doctors.

    This disrespect may stem from the hierarchy seen in the medical system, as well as in part due to sexism from predominantly male doctors to female nurses. But with steady progress these days, medical organizations emphasize teamwork and “flattening” the hierarchy, and the younger generation of doctors and nurses often embrace respect for all regardless of gender.

    As a counter point, I have heard many stories about older nurses giving new doctors a hard time (I.e. lack of respect), almost to the point of hazing. It goes both ways. This is not to sensationalize problems between doctors and nurses, but to highlight we are all people with insecurities and emotions. How we understand ourselves better for the benefit of patient care will be challenge, not using a scoring system. (Technology is great for sure! But I wonder how we will truly digitize human care. Is that even possible without changing its essence?)

    If we want to go back to stats and a scoring system, how many times were nurse’s gut feelings wrong? Doctor’s too. See recent op-ed from Dr. Sekeres piece from Aug 7.

    We are human, no one is perfect. But we all should take the time to care for one another.

  222. @A Doc
    Well say!
    I will add that too much emphasis in team work and collaboration may delay the decision making process that it is critical with patients

  223. Jonah Lehrer's excellent book "How We Decide" really aided my understanding of, and thinking about, the nature of gut feelings and the ways they represent long term accumulations and integrations of experience, as did this thoughtful essay. Once, 33 years ago, when a medical trainee glibly wrote off something I had observed about my daughter's physical adaptations to a disability, his doctor/mentor admonished him immediately and told him that a parent's constant experience of a child was one of his best diagnostic tools. I was very grateful for the encouragement this gave me to be a forceful advocate for my child in a medical establishment that tended at that time to dismiss me as a "nervous mother."

  224. @Sue Ann Dobson

    Indeed, "a parent's constant experience of a child" is a critical piece of the diagnostic process. I, and I am sure many of us, have had the experience of insisting our child be seen (or pushing the M.D. to look deeper) because the child's otherwise subtle symptoms raise big red flags to those of us who know their every state. In this way I've caught many a strep throat, allergic reaction, sepsis, pneumonia and mono that had been dismissed as something less. The same is true of our constant experience of our spouse or other loved ones - valuable insights and red flags can gleaned from these careful observations we provide. Rather than writing us off as "nervous" or "anxious", an observant and experienced nurse can often put it all together, saving lives and alerting M.D.s to impending problems. Good healthcare professionals of all kinds, teachers, parents and others use their experience and go beyond the numbers to direct their care. I am always grateful for an experienced nurse who knows how to listen.

  225. The experiential intuition learned by intelligent, interested professional in any field is invaluable in evaluating any human affliction and developing and applying an effective solution. Medical doctors, as opposed to those educated in the Osteopathic tradition, are trained in a strictly linear method of collecting and evaluating patient information and become focused on a very limited amount of evidence. Nurses, most of whom are still women, come to medicine with a non-linear, whole-person view of their patients and therefore are able to access information and see events outside the strictly linear approach. Their experienced "feelings" are really a highly developed intellectual sight that allows a more accurate assessment than a strictly linear approach--the "art" of the professional healer, if you will. Any true medical breakthrough in treatment of a disease process has been accompanied by a scientist who sees beyond the linear "scientific" tests into the broader relationships of the phenomena he or she encounters, thereby opening up the non-linear mind to all the facts and their relationships of the particular phenomenon under observation and ambition to develop a solution.

    Any lawyer doing good plaintiff medical malpractice work knows that the real facts are in the nurses' notes.