As a veterinarian, I’ve relied on intuition to guide me far more often than I like to think about.
About two weeks into my internship, and only a month out of veterinary school, I found myself in charge of a tiny terrier named Murphy.
Murphy was initially thought to have a digestive problem, however tests were inconclusive, including biopsies of his intestinal tract, so his care was transferred over to one of the internal medicine specialists at our hospital. I was the intern on their service, and it was my job to arrive at the hospital early in the morning and prepare Murphy’s case for the new attending doctor.
I arrived at work before sunrise, and was “rounded” by the night doctor who admitted Murphy. She updated me on all aspects of his care, including the results of his diagnostics thus far.
Murphy was a complicated case, so I decided to begin by reviewing the radiographs (X-rays) taken before Murphy went to surgery. On the films centered on his lungs, I noticed changes that were concerning for a suspected condition called megaesophagus.
In megaesophagus, the esophagus (the tube connecting the mouth to the stomach) becomes severely dilated, causing any ingested material to become lodged within its floppy recesses, and animals will often passively regurgitate food with the simple flow of gravity.
Megaesophagus can be a primary problem, but also can occur secondary to a number of other medical conditions. While my eyes scanned the films, I distinctly remember the stirrings of what I now know to be my “doctor” intuition, which was thirsty to know why it was that Murphy had this rare condition; could this be related to his signs?
I examined Murphy and noted he was lethargic, but able to rise with stimulation. I routinely completed my exam, with nothing seeming out of the ordinary, until I tested Murphy’s ability to blink in response to a light tapping on either side of his eyelids. His reflex started out strong, but quickly diminished and altogether ceased after about ten taps on both sides.
It was then that my intuition advanced from a gentle churn to more of a steady growl. I decided to consider these inklings the best way I knew how at the time (and am still guilty of practicing from time to time): by stalling and taking my patient for a walk.
After I unhooked Murphy from his tangled web of IV lines, while sauntering down the hallway, he suddenly emitted a guttural sound that seemed to emanate from the deepest depths of the core of the Earth. I turned and watched as (without missing a step) he spewed forth a large wad of undigested food. Murphy exhibited no signs of retching or increased salivation or other premonitory signs. In fact, there was barely a pause in his stride, as if the material he expelled was more of a nuisance than anything related to nausea.
It was then that I patched together Murphy’s signs: his waning energy, his fading blink reflex, his megaesophagus leading to regurgitation (not vomiting) — these were all signs seen in patients with a rare neuromuscular disease called Myasthenia Gravis (MG).
MG is an autoimmune condition where the body attacks a receptor protein responsible for helping transmit impulses from nerves to muscle cells. When the receptor is blocked, signals are stunted and pets show signs of profound weakness. The disease affects not only muscles moving the body, but also muscles within the digestive tract, including the esophagus, leading to its expansion and inability to transmit food.
Once I pieced the puzzle together, I faced the challenge of mustering up the confidence to tell my senior clinician my theory. There I was, but a “baby doctor,” lacking the confidence and assertiveness, yet possessing enough concern for my patient to risk ridicule. I stammered through letting my attending clinician know my thoughts, apologetically stating, “I know I am only an intern, and I don’t really know what I’m talking about, but my gut tells me Murphy has Myasethenia Gravis.”
Much to my (and Murphy’s) fortune, the internist did not discredit my feelings. Perhaps his intuition told him the same things, or perhaps he didn’t even need intuition at that stage of his career, but he ultimately ran the tests necessary to prove my theory, and together we diagnosed Murphy with, and successfully treated him for, MG.
Since those days, intuition has served me time and again as a veterinarian — whether it’s second-guessing a test result or an owner’s level of understanding of my information. I listen to the voice inside or the feeling in the pit of my stomach, or whatever it is that causes me to pause when the pieces just do not seem to connect.
Nowadays, I tend not to pay much mind to my intuition when it’s right — except in cases where I’ve decided to ignore the warning signs and go against my feelings. It seems I’m focusing more on what happens on the contrary, when my suspicions are wrong. And I struggle with the asking myself, “In such cases, can I still call it intuition?”
Doctors are constantly struggling between reconciling our book knowledge and our instinct, and the more cases I see, the more I know when to express skepticism or recommend “just one more test” because I am heeding the concerns of an inner voice. Such proficiency comes with a surprising degree of insecurity, which is only amplified when that voice is incorrect.
I think I’ve come to realize that experience isn’t the entity bridging the gap between intuition and self-doubt, but rather the nature of the case itself. And the barometer will swing from side to side, from patient to patient, with some cases better assessed towards one end, and others towards the other end.
I still listen to the voice within more often than I’d like to admit. Dogs like Murphy let me know this is a perfectly fine way to practice medicine.
Dr. Joanne Intile