Yesterday, I briefly discussed evidence based medicine. I hope I left you with the understanding that I firmly believe in EBL, but I believe in it as a tool, not an end in itself. In “Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like” (Changing Health Care in Canada: The Romanow Papers, 2004) Glouberman and Zimmerman point out that Complex Adaptive Systems, like health care, exhibit a “great deal of noise, tension and fluctuation as they interact with the rest of the environment” and that this represents not a negative, but an opportunity! Let’s explore this Yin and Yang of metacognition and intuition in medical practice and education.

Two very bright stars in this discussion are Professor Trisha Greenhalgh, a primary care physician at University College, London, and Professor Mark Quirk at the University of Massachusetts, Worcester. Both have written extensively on the creative tension between evidence or metacognition and intuition in medical practice. Metacognition is the ability to “think about our thinking”. In some respects, this is the “double loop learning” of Argyris and Schoen. Evidence based medicine is one of its inputs. It is the “cognition” part of “metacognition”.

In “Intuition and Metacognition in Medical Education”, Quirk identifies the “knowledge dilemma” in medicine: “there’s too much, it is changing rapidly and some of it is of little use”. He quotes Alfred North Whitehead’s statement that, “knowledge keeps no better than fish”. The key is to develop medical expertise through effective lifelong learning. This is the capability to assess, monitor and improve performance through planning, goal setting and reflecting. In “Intuition and Evidence: Uneasy Bedfellows?” (British Journal of General Practice, 2002;52:395-400) Greenhalgh states that evidence based medicine is undeniably important, and yet points out that there is little evidence that knowledge per se improves decision making.

Both state that something else is needed to develop real expertise. They term this quality “intuition”. In the popular press, Malcolm Gladwell described this as “rapid cognition” in “Blink” ( He purposely avoided the term intuition, but he, Greenhalgh and Quirk are describing the same operation.

All three agree that there is a difference between this rapid cognition and flippant unschooled crackpot opinion. Intuition can be developed, honed and improved. How? You may have guessed it: through metacognition (Quirk) or through metacognition-by-another-name, Balint Groups (Greenhalgh). Not well known outside of the UK, these are formal group reflection sessions aimed at physicians, and have some degree of success.

The Balint Group opens up narrative as a tool in medicine and medical education. That’s a whole other topic!!

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