Personal views: In praise of hunch backing
Authors: Richard Lehman
Journal: BMJ (1999)

The backing of hunches in medicine seems to have fallen out of favour. So unfashionable are anecdote and opinion in these days of evidence based medicine and molecular genetics that the poor hunch backer may soon have to eke out a lonely, mad existence in the cathedral towers of medicine. Shunned by the Esmeraldas of funding, we will be forced to live on kindly gifts of bread and cheese, while we leap about groaning, “Why were we born so ugly?”

Time was when hunches were the stuff of medicine. Ambroise Pare had a hunch that wounds might heal without boiling oil; John Hunter that soot might be bad for chimney sweepers' scrota; Will Pickles that common infectious diseases did not have the same incubation periods in Wensleydale as they had in textbooks. But through the centuries there also ride troops of medical knights whose hunches were wrong, but whose armour was proof against all contradiction. For every Harvey Cushing there were a thousand Lancelot Spratts. And in our own time there strode the mighty figure of Denis Burkitt, completely right in his hunch that a virus could cause lymphoma, and completely wrong that lack of fibre could cause bowel cancer. We have learnt to ignore the anecdotes and preachings of the great, until proven by someone else's boring hard work.

Now general practice can be boring hard work, but at least it is your own, and done for the direct benefit of individuals you know. That is its main attraction. You can become a general practitioner without any of the research obligations foisted on aspiring consultants. But after five or 10 or 20 years, your constant contact with people experiencing illness may start giving you hunches. Perhaps, like most hunches, they are wrong, but being your hunches, they might be right, and at least they interest you. So you go to the evidence. Either it has all been done before, and you realise how ignorant you are, which is always salutary, or there are some papers which look interesting, but may turn out to be about mice in Barcelona, or perhaps there is nothing at all. Not from primary care, at any rate, and not quite matching what you have spotted.

Then what do you do? An awful crisis looms in your life. You can forget your hunch, but the daily grind will become thereby more grinding; you will dream wistfully; you will wear an air of dissatisfaction; and you will drive to the wrong addresses on your calls. You may go into medical politics; sit on endless committees; go on away days; brainstorm. But stop, this is becoming too painful to contemplate. No. There is no choice. You must follow your hunch. It will lead you to libraries, cyberspace, academic departments full of odd, helpful people, scrambles for funding, which, when you have got it, means time out. To follow your hunch. 

How do you get the money to make the time to get the money to get you started? This is perhaps the most difficult obstacle for the hunch backer. Fortunately, there are various schemes, mostly run at regional office level, which can help potential general practice researchers get started. Many of us hoped that in the wake of the Culyer report there might be a national drive to help individuals in primary care who wanted to get on to the research ladder, but by and large this has not happened, and most academic departments survive from grant to grant and have few resources to help the hunch ridden. So ask around, and have a go at whatever is on offer—hoping that one day the central funding agencies will realise that general practice contains a vast resource of motivated individuals with long term commitment and ready made patient cohorts.

What follows then matters little, really. You may have a hunch about coeliac disease and change practice with a key paper, like my partner. Or you may have a hunch about heart failure and get going, only to lose yourself in the complexities of your subject, like me. You are bound to do some good, even if it is only keeping your brain active and producing guidelines about something or other. And yes, you will be doing what you became a doctor for. One way or another, you will be helping to make poorly people better.