Uncertainty, over-cautiousness and assumptions: How clinical reasoning got crushed during the COVID-19 pandemic

Even our wildest nightmares in the earlier months of the year wouldn’t have hinted about the incalculable magnitude of the loss we are facing in postgraduate training. Our confidence that the virus wouldn’t cause much havoc in tropical countries like India shattered like bad crystal falling unceremoniously upon the wood floor and the vogue lock-down dramatically reduced the number of teaching cases for months on end.

Our bedside learning teaching activities suddenly transitioned into online domains where the nuances of skills training was equated with hours of SOP / guidelines monologue and slowly we started disorienting ourselves from our reasoning abilities as well. Uncertainty is not uncommon in postgraduate residency and we could say that experts etch themselves out of diagnosing ill-defined or vague features. But the uncertainty surrounding this pandemic is something we have never encountered before.

The flexibility of the iterative diagnostic process was compromised because both patients and authorities weren’t intentional enough in tolerating uncertainty. Everyone had their own sense of urgency and bounded rationality. Patients and their supporters were concerned about the social stigmatization in the earlier months and so were concealing crucial parts of their histories. In subsequent months, emphasis was levied on prescribed pathognomonic pattern of disease and this lead to representative bias. The pressure to diagnose COVID-19 circumvented the basic need of asking the simple things like a history of exposure to allergens in the living room. Even an experienced clinician decides to take a swab the moment he developed an irritation in his throat. Such is the level of ‘anchoring’ induced by the disease incidence and prevalence.

Why so? Why have we conveniently ignored the hard-earned and reliable reasoning skill at time of this pandemic? Why could we not intentionally reason or self-explain or hypothetically-deduct when reality confronts us? Simple. Our training was more on certain grounds and the cases used for our training were grounded in contextual factors. We reason well when we stay emotionally composite and follow a well-practiced structural paradigm of case solving. Encountering multiple independent variables in an emotionally vulnerable dilemma forces us to adopt intuitive reasoning and a reductionist coping strategy. This wasn’t learned in conventional clinical reasoning sessions where we simply solved narrowly designed case vignettes without much emotional distractions or contextual noise.

What’s next? The pandemic outbreak is a clear example of ‘disorienting dilemma’ in the field of clinical reasoning. It has transformed our way of thinking and obviously, the way clinical reasoning has been conceptualized. We don’t know when we shall be rid of COVID-19 as a diagnosis at hindsight and start reasoning in analytical fashion as before. As the days pass by, the fear of contracting the disease from random patient encounter also escalates and this indeed might increase the dis-junction and cognitive fatigue.

We have been taught that clinical reasoning and decision making are not a bed or roses. It is indeed a bumpy road of handling tensions, navigating uncertainties, learning from failure and not succumbing to cognitive biases lurking in our brains. But, we could not deny the fact that post-graduate residencies all over the world have suffered a worst hit during this time of pandemic and unlike other turmoil, we don’t have a hint about the salvage point. The only thing at our hands is using the uncertainty to shape ourselves and develop adaptive expertise of decision making in the “new normal” ward settings.

Dr. Dinesh Kumar, Assistant Professor, Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Dr. Shuriya Prabha, Postgraduate resident, Department of Paediatrics, Rajah Muthiah Medical College, Tamil Nadu, India