Several years ago, I left my medical practice for a long vacation. On the morning of my first day back, my alarm went off. I pushed the button in and, for a few minutes, lay with the light off. Then, one at a time, I lowered my feet to the floor. The slow process that would transform me back into an anaesthesiologist had begun.
But something was wrong. I felt uneasy about my ability to perform my duties as a physician. Some kind of inner harmony was gone. Before my vacation, I had enjoyed the pleasure of working along a single groove, endlessly repeating surgical cases with unwearied regularity, and making snap decisions with confidence. The unexpected had never really startled me, and, at times, I even hoped for something out of the ordinary. Now something was different – off. I was filled with doubt, born of I knew not where, to which I returned unceasingly. How was this possible? One day I was perfectly fine, and now, after just a few weeks away, confidence and sureness were gone. Simply put, I had lost my professional intuition. Although that explanation may seem imprecise, intuition is real, and, without it, experts lose their bearings. What had once seemed sure and certain for them becomes a question for enquiry.
Researchers have long recognised intuition’s relevance to professional judgment. In 1938, the businessman Chester Barnard wrote the now-classic book The Functions of the Executive, in which he described two distinct forms of managerial decision-making, logical and non-logical, with intuition an example of the latter. In 1957, the scholar Herbert Simon coined the phrase ‘bounded rationality’ to illustrate the same division. The psychologist Daniel Kahneman spoke of two systems for decision-making: ‘System 1’ for intuition, and ‘System 2’ for deliberate and analytical thought. In the 1960s, the neuroscientist Roger Sperry attributed logic and reason to the brain’s left side, and intuition to the brain’s right. More recently, the division has been used to distinguish between personality types, as in the Myers-Briggs personality model, where a person can be ‘intuitive’ or ‘analytical’.
Intuition was pigeonholed in this way not merely to try to understand it, but also to control it. For, within the secular world, intuition is the sole survivor from those primitive days when people credited human behaviour to mystical and spiritual forces, and science was inseparable from divine doctrine. Most of those forces were elbowed out of existence in modern life, and consigned to the religious sphere. But intuitive thinking was too useful a professional tool to simply be tossed aside. Even today, more than 60 per cent of CEOs rely on intuition, or ‘gut feeling’, to guide their decisions. Under some circumstances, 90 per cent of intuitive decisions prove correct. Nevertheless, the concept of intuition threatens science, upon which much of modern professional life is based. Science uses logic, observation and measurement to find truth, while intuition, derived from the word intueri, which means ‘to look within’, seeks truth through inner contemplation. The latter method harkens back to a dark age before clarity and frankness came to dominate the realm of thought. Thus, while given its due, intuition had to be contained within a well-ordered system that downplayed its connection with mystical thinking.
‘Intuition is nothing more and nothing less than recognition’ prompted by a cue, Simon wrote. In the mind sit memories stored away in oblivion, which, when cued, return to consciousness because a temporary use for them has been found. Simultaneously, a feeling of certitude arises. There is nothing miraculous about any of this, researchers insist.
Yet, it is when professionals lose their intuition that its mystical value shines through. For, in tough cases, when facts are lacking and the path forward is unclear, intuition arrives like a revelation. Intuition is an article of faith we assent to when reason has reached its limits. Belief in that revelation is what puts intuition on an altogether different plane of cognitive experience. There can be no relation between intuition and reason, not because they work through different sides of the brain. Instead, it is like the difference between the infinite and the finite; the infinite is out of all proportion to the finite, so that no comparison or analogy can be established between them.
Professionals who lose their intuition also sometimes lose their will to act. Faced with a difficult case, the feeling of certitude that accompanies intuition helps turn thought into action. Without it, doctors like me might hesitate to do anything at all.
To accept intuition as revelation, it’s as if the world had not yet undergone division. Belief and knowledge unite, mystery ceases to be anathema, and the science of decision-making, no longer parsed between rational and irrational, acknowledges an element that surpasses human comprehension, on par with the universe or eternity.
I entered the hospital that morning with a shiver, and greeted my first patient, a woman going for in vitro fertilisation (IVF). I knew I would never mention my feeling of doubt to her. Yet, in the back of my mind, I feared I would never part with it.
She had a history of asthma. She had also been caught chewing gum, which was a problem. Gum chewing raises the risk of aspiration under anaesthesia, because it causes the stomach to secrete gastric juice. I debated whether to delay the case. On the one hand, doing so was almost unheard of, as egg retrieval must occur within a narrow time frame and prospective mothers are loathe to miss it. On the other hand, aspiration carries the risk of an asthma attack, pneumonia or even death.
In the past, I would have made the decision easily. How is that, I wondered? In regard to gum chewing, there is no exact rule. Yet, everything I used to do in the operating room, I used to do thoughtlessly; the right course seemed plain and simple. Now, no matter how much thought I gave to the matter, and however much I examined it from every possible angle, my mind kept floundering in a welter of indecision and doubt.
Anxiety aroused in me wild imaginings that neither my knowledge nor my clinical experience could dispel
The patient cried when I told her we might have to delay things. The surgeon rolled his eyes. He was not out of line. As a surgeon, he valued anaesthesiologists for their acquiescence and adaptability, yet he also thought my concern too theoretical. Perhaps he was right. Life for a doctor is full of pitfalls; it is dangerous to be foolish, and it is also dangerous to be intelligent and overthink things; dangerous to others, and, no less, to oneself.
I asked another anaesthesiologist for her opinion. She laughed, and said of course she would proceed. Although she probably thought less of me because of my confusion, I enjoyed our short moment together. Somehow, she was a link to my old life, when I had my intuition, and decisions flowed naturally and easily from my mind.
After deciding to proceed, I thought briefly about giving the patient a spinal anaesthetic, so she would be numb from the waist down but awake. That would lessen her chance of aspirating. But using a spinal anaesthetic in an IVF case was almost unheard of, so I elected to put her to sleep. Yet, I had another decision to make. Should I insert a breathing tube in her airway while she was under anaesthesia? Doing so would protect against aspiration. Then again, I never had to do this for any IVF case in the past. There must have been a good reason why not. I just couldn’t remember it. What confidence I must have had in those days! I thought. I floated out loud the idea of placing a tube to see what others in the room might say. ‘You’re joking, aren’t you?’ said the nurse. I nervously smiled back and nodded, hoping to conceal the fact that I had been undecided, and pretending to be just another doctor who knew his business.
The science of decision-making can account for several of these events on perfectly rational grounds. The neuroscientist and psychologist Joel Pearson, author of The Intuition Toolkit (2024), has an acronym, SMILE, to explain them. I had violated three of his rules. The S stands for self-awareness, especially one’s emotional state. In my case, fear and anxiety had compromised my ability to think intuitively. The L stands for low-probability. In my case, I had overestimated the chances of an anaesthetic complication, similar to how people overestimate the chance of being struck by lightning during a gentle rain, which had confounded my intuition (what Pearson calls ‘misintuition’). The E stands for environment, where intuition works best in a familiar and predictable environment. In my case, being away from the hospital had caused my environment to seem unfamiliar.
Yet, science is incapable of creating a chiaroscuro for mental happenings. Science demands order and light, and has no place for that twilight realm where the transition from rational thought to spiritual confusion begins.
That morning, I asked myself why my medical intuition, which, over the years, had struck its roots deep into the ground, had begun suddenly to hop about from place to place. The answer was terrible: although I still had all my professional knowledge and clinical experience, something had given way in my mind, a crack had opened, and I stared through a narrow black fissure into a void. I read five journal articles that discussed gum chewing and anaesthesia. Yet, the circumstances in each study were slightly different from my own case; also, the studies disagreed with one another. Even when clustered together to intensify their warm and comforting effect, to make medical practice seem well-ordered and predictable, five journal articles offer no guarantee, no sure thing. They are like stars in the night sky that shine bright, and warm the heart, and seem to give life secure limits, but nevertheless exist in that unnamable Nothing, the alien, cold and dark universe where people come face to face with the unknown. Nothing had really happened, but my anxiety aroused in me wild imaginings, and neither my knowledge nor my clinical experience could dispel them. The anaesthesia monitors seemed to become transparent, like shadowy lights in darkness. And, when that darkness enveloped the operating room, I trembled before the infinite.
The great 20th-century violinist, Yehudi Menuhin, described a similar experience when, as a young man, he lost his professional intuition, causing his violin playing to suffer. In his memoir Unfinished Journey (1976), he wrote: ‘What had happened was a break in sequence. Between musical vision and its communication, a transition hitherto made intuitively, there occurred … a rupture which brought all to naught. Intuition was no longer to be relied on; the intellect would have to replace it.’ But intellect was not enough. He continued to play badly. ‘How many people walk badly, breathe badly, chew badly, digest badly? Such is the price of a civilisation which has left intuition behind and not yet discovered the way back,’ he moaned.
How do professionals find their intuition after losing it? How can they give themselves what they do not have? Some psychologists say intuition can be coached or taught. In The Power of Intuition (2003), the research psychologist Gary Klein says the intuitive method can be rationally communicated to others, and enhanced through conscious effort.
Menuhin’s intuition finally returned to him when he accepted the limits of his own reason
Yet, the experience of another great intuitive violinist, Jascha Heifetz, suggests otherwise. By his own admission, he failed to understand the intuitive process, let alone teach it to others. He analysed himself religiously, sometimes watching videos of his rehearsals in slow motion to study his hands moving eight times slower. But, as the violinist Erick Friedman said about Heifetz and intuition: ‘He doesn’t understand the sources of his own genius. That is a part of his dilemma.’ Nor was he able to teach it to others. He was considered a poor instructor. One violinist said of him: ‘Heifetz is intuitive, and it is impossible to communicate intuition.’ Of all his pupils, only one became a soloist; the others became players in an orchestra where, Heifetz admitted, they just ‘contribute to the noise’.
That morning, I had tried to reclaim my old intuitive self by reviewing, in my mind, some of my old decisions. But discovering their secret ingredient proved impossible. Those older decisions were built on a continuous flux of emotions, ideas and memories, none of them beginning or ending, but all extending into each other, leading to an impulse that had moved me a certain way. When turning back and looking for that impulse, to understand it and reclaim it, I found it was gone, for the impulse was not a thing but a direction of movement, which, while simple, is indescribable.
The mystery led Menuhin into the metaphysical. He wrote, the ‘harsh whips of determination cannot drive one to performing pitch … one is led there by the quiet exercise of principles grasped by the mind and absorbed by the body over stubborn years of faith’ (my italics). He travelled to India. He absorbed the Hindu belief in one force binding all creation. He gravitated toward beliefs in hatha yoga. His intuition finally returned to him, he suggested, when he accepted the limits of his own reason. ‘When we are faced with 10 different factors, all acting upon each other and among them creating some astronomical total of variables, reason is defeated and only intuition can cope,’ he wrote. For whatever reason, on his return from India, he regained his intuition; he believed in it again, although he gave up the notion that he could understand what he believed.
The searches of Menuhin and Heifetz are eerily analogous to the path people trod centuries ago in their quest to understand some higher reality, when they questioned, hoped, studied and prayed for better understanding, and when knowledge and belief were one. Theirs was called a spiritual search. While science may try to show the absurdity of this game of God-chasing, professionals must resort to it at times; it is an inevitable phase in their mental life. Science and method can give knowledge, but knowledge alone is not enough to lead a professional into the recesses of their own mind, even when they want to go there. No synthesis of our bits of knowledge will ever equal the truth about intuition at which they aim.
After my patient lay down on the operating-room table, I prepared to insert her intravenous. Yet, the instant I readied the needle, self-consciousness arose in me. I thought of all the precision needed to get an intravenous in, and how fragile any person’s plan for doing so really is. I began to second-guess my angle of approach. I thought about how I had not placed an intravenous in weeks. Clenching my teeth, I took aim and plunged the needle with unnecessary force into the spot. A mound of blue blood swelled just underneath the skin. I had missed the vein. I tried and missed again. The nurse stared at me wide-eyed. Fortunately, I succeeded on the third try.
Here, the science of decision-making offers a good explanation for what happened. Pearson describes intuition as the learned, positive use of unconscious information for better decisions or action. To perform well, we must sometimes operate reflexively – what Pearson calls ‘blindaction’ – as when flinging out a foot to deflect a soccer ball. My error was to rely too much on conscious thought to place the intravenous, which caused my rhythm to break down.
The operation began. While working, the surgeon and nurse talked happily about how they had spent their weekend. The conversation could have amused me if I had wanted to be amused. But I did not want to be amused. I was worried about what might go wrong. The anaesthetic was amusement enough, occupation enough, torture enough.
One voice encouraged me to hold off injecting a medicine, while another prodded me to do so
The case finished 20 minutes later. While emerging from anaesthesia, the patient coughed, her airway obstructed, and her oxygen level fell. She was in laryngospasm, most likely because gastric juice had dripped out of her stomach and touched her vocal cords, causing them to snap shut – the very thing I had worried about. My best option was to give her a short-acting muscle paralytic to relax her vocal cords.
But she had a large burn scar on her leg, and the drug is contraindicated in such situations because of a possible dangerous release of potassium from the muscles. How large did the scar have to be to provoke such a release? The textbooks were not that precise. I had dealt with this conundrum before, always making the right choice and never having to resort to the safer, but longer-acting, paralytic. I wondered how I had reached those decisions. I was living backwards; I was a better doctor in the past, and from that past I was trying to extract the mindset that had produced such good decisions.
It seemed stupid not to give the short-acting drug. But a feeling within me advised otherwise. I could not make out the nature of the feeling. It was akin to a stomach upset, just as nauseating and terrible. There was fear; the drug might provoke a dangerous potassium release. There was also a queasy sensation of regret for not having used a spinal anaesthetic. Then there was embarrassment for having the complication in the first place. The feeling inside me was strong, and I couldn’t disentangle it from the more general feeling that this was an unusual situation that demanded use of the longer-acting paralytic.
I also found myself yielding to the delightful idea that, if I simply did nothing and left things alone, everything would be fine. Although laryngospasm is a dangerous complication, it sometimes disappears on its own. Just let things be, another voice inside me said. Yet, I parried all the good reasons for doing so with other reasons for treating the problem. For example, the patient might suffer a lack of oxygen before the laryngospasm broke. One voice encouraged me to hold off injecting a medicine, while another prodded me to do so. I had no idea which inner voice to listen to.
I sighed, I hoped, I feared, I doubted. The case lay motionless for 30 seconds, not under any command. Then, impulsively, I injected the longer-acting paralytic. Because the drug would paralyse the patient for an hour, I had to insert a breathing tube and bring her to the recovery room re-anaesthetised. There, everyone knew what I had done. I forced myself to look them in the face. When I did, I met their reproachful glances. I waited at the patient’s side for the drug to wear off. When she woke up, I removed the tube and went back to the lounge feeling very distressed.
According to Pearson’s SMILE acronym, this new set of problems arose because I had violated the I, which stands for impulsive thinking that is mistaken for intuition. People imagine hearing within them a commanding inner voice that they wrongly credit to intuition. Still, science alone fails to expose the mistake’s deep structure. Because I lacked intuition and certitude, a void opened up inside me, which other voices rushed to fill. When we lack certitude, our minds censor, rationalise, and create ideas that seem to be relevant, but which are, in fact, invented by us. When a person is fiercely intent on hearing a particular something, it is hard not to acquiesce even slightly to just a particle of that something. And, because we cannot tolerate the idea of being unable to understand ourselves, we ineluctably make a system out of that something, and organise our thoughts to make it seem coherent. Anchored in personal bias, prejudice, vanity, hope or a moment of wilful ignorance, that system then masquerades as intuition, causing us to act impulsively.
In a difficult situation, of course, the natural thing to do is to not act, thereby avoiding injury to oneself or one’s client. Nevertheless, action is sometimes necessary, and, for that, one needs the will. When certitude cannot arise through reason to motivate the will, it arises instead through a leap of faith in one’s intuition.
Dwight D Eisenhower exemplified this point on the eve of the D-Day invasion. The weather was bad. Delaying the invasion risked mission secrecy, as well as cutting into the time the Allies had to campaign during good summer weather. Yet, proceeding amid wind and rain risked the absence of air cover during the landings. Another issue was whether to activate the airborne operation that would drop forces behind enemy lines. Several of his advisors had warned him that the paratroopers would be massacred. Yet, cancelling the airborne operation put the shore landings at risk. It was a ‘soul-racking problem’, Eisenhower later admitted.
‘I took the problem to no one else. Professional advice and counsel could do no more,’ he wrote in his memoirs, Crusade of Europe (1948). Inside his mind, he heard different voices, all competing for his allegiance. It was as in centuries before, except then it was the gods, the unseen powers, who supposedly revealed themselves to generals in the form of whispering voices, filling their minds with fears and hopes, threatening and exhorting. He reluctantly postponed the invasion by a day. He seemed uncertain whether to proceed at all. He paced up and down the room, ‘hands clasped behind his back, chin on his chest’. Finally, after thinking things through as best he could, he reached a decision – intuitively. He looked up at his commanders and said: ‘OK, boys. We will go.’
Science may explain why intuition fades, but why it returns seems mysterious
Whether he had judged rightly or wrongly, Eisenhower at the time didn’t know. Nevertheless, he believed in his intuition; he had faith in it. And, with that faith came the will, that uprush of volcanic energy, that discharge from the unconscious needed to get things done. Once Eisenhower made his decision, there was no second-guessing himself, no regrets, no vacillation; just an underlying strength of determination that radiated outward to his advisors, and then to the thousands of soldiers under his command. An aroused will brings everything inside that person under one yoke, giving him or her the courage of conviction vital to action when the way forward is unclear.
I, on the other hand, had acted impulsively that morning, then I had second-guessed myself in a way Eisenhower had not, which is telling. ‘Coolness’ is often the quality that distinguishes the professional with intuition from the one who lacks it. It is easiest to observe in the person’s facial expression. The expression in the former invariably reads: ‘I’ve done all I could do; now I’ll wait and see what happens; while waiting, perhaps I’ll think of something else.’ In the latter it reads: ‘Was I wrong? Oh, why did I do that? I should have done otherwise. Or maybe not?’
When I lost my intuition that morning, it was as if something had hit me, or simply settled on me softly like a bird settling on a tree; I had grown wooden and inflexible, and lost all feeling, as if I had turned into a tree myself. Fortunately, the malady took its normal course, and my intuition returned to me by the end of the day. How or why, I do not know. Science may explain why intuition fades, but why it returns seems mysterious.
The most recognisable change, as my intuition returned, was my attitude toward doubt. During the IVF case, it was as if doubt were a person who kept tapping me on the shoulder, interrupting my thoughts, and saying: ‘I know you’re busy, and I don’t want to bother you, but I have been here all this time, and I don’t intend to leave you.’ Every time I was on the cusp of making a decision, doubt was there to convince me otherwise. I wasted much time and energy that morning wrestling with doubt.
I resented doubt’s presence. I imagined myself once practising medicine doubt-free, as if the days before my vacation had been happy youth, something to be remembered as dear and pleasant because now they had passed away. But, over time, it dawned on me that there had never been a time as a doctor when I had been free of doubt. Imagining there had been was an illusion.
As I grew comfortable again living and practising medicine with doubt at my side, I felt the tide of self-consciousness flowing out of me, like a child at play. The change in mindset is comparable to what happens in chemistry when dropping liquid into what appears to be a clear, watery solution. Nothing changes, then suddenly the solution becomes saturated. One more drop and the contents come alive; instead of water, one has gleaming crystals – in my case, intuition. When the change occurred, it was as if doubt had whispered to me: ‘So now you know, I am always here. Go where you will inside the hospital, I will travel with you. I am your master, but you are also mine.’
Science tends to view life as an empty, soulless place, an inert, unspiritual void. Even when it recognises irrational forces, it aspires to tame them by placing them inside a model, keeping the primal beast imprisoned behind the iron bars of knowledge. But, for an expert professional, real life is quite otherwise. The expert’s mind is not binary, nor is it wholly amenable to understanding through knowledge gained piecemeal in research. Instead, it is permeated by invisible waves that can only be sensed by the inner faculties. It is full of mysterious streams and tensions that constantly touch and enliven each other. Intuition is just another name for this heavenly harmony.
