When covid-19 emerged, all doctors were faced with a new disease about which they knew little. Anna Hammond describes how the experience has changed her consultations with patients and how she teaches medical students
Clinical reasoning describes the thinking and decision making processes we use while practising medicine. It is a complex cognitive process. Dual process theory is a widely accepted model of clinical reasoning1: it posits that as experienced clinicians, much of our day to day decision making uses a swift type of thinking (pattern recognition). However, when patients present with symptoms or signs that “don’t quite fit,” we switch to the more conscious, effortful second type of thinking, which, among other things, allows us to be systematic, reflect, and think hypothetically.2
Medical students can often be mystified when they observe the first type of thinking in action, whereby an experienced doctor will ask a couple of simple questions and then make a “clever” diagnosis. It can be difficult for students to understand how they arrived at their conclusion, since their clinical reasoning ability still rests on the more deliberate second type of thinking.
As an experienced clinician, it is easy to forget what it felt like as a student. Until covid-19, my closest experience was attending swimming lessons. I was trying to learn an effortless front crawl like the swimmers executed in the fast lane, and I found it frustrating to have to break this skill down into its constituent parts and practise each repeatedly.
Yet then in 2020 the world changed in a way we could never have imagined. We all, whether clinical reasoning beginners or experts, were faced with a new disease about which we knew little. In those first few weeks in March, none of us had patterns (illness scripts) to recognise for patients with covid-19. We were all novices, and it’s incredible to think how far our understanding has developed since those early days when our clinical reasoning was mainly focused on a travel history from China or Italy with a cough and a fever.
The pandemic reminded me what it feels like to be a student in clinical reasoning again. I had countless discussions with colleagues, trying to learn from other doctors who had consulted more patients with covid-19 than I had. Covid toes, rashes, abdominal pain and vomiting, “off legs”—could these be covid? There was something very levelling about learning the illness script of a new disease from scratch again.
As the days turned into weeks, I noticed that my consultations were changing, not just when I suspected the diagnosis to be covid-19, but with other conditions too. Consulting remotely, mainly by telephone and without the visual cues of a patient in the room, I was really listening to what people had to say. I was encouraging patients to tell their story in their own words before clarifying biomedical information that would help my reasoning. I realised that I was explaining the thought process behind my clinical reasoning in much more detail with patients, discussing the likely cause of symptoms with them and being more explicit in my safety netting advice.
I’ve often observed that as medical students progress through their training, they tend to move to a more closed approach during their clinical reasoning, forgetting the importance of hearing a patient describe their symptoms in their own words. Watching students consult remotely has given me real insight into the pitfalls of students using a series of closed questions, particularly SOCRATES (Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/relieving factors, Severity), rather than encouraging a patient to just tell their story in a more open ended way.
The lack of distractions in the consulting room and being unable to undertake a physical examination has meant that for doctors and medical students, we’ve had a heightened focus on really listening to what the patient was saying. It’s provided an excellent opportunity to reflect individually and with students on the need to listen.
Now I’ve reached the anniversary of my first covid-19 consultation, I realise just how much the pandemic has shown me that Osler was right: if you listen to the patient, they really do tell you the diagnosis.
Anna Hammond is academic lead for clinical skills and reasoning at the Hull York Medical School and a practising GP in York. She co-founded the UK Clinical Reasoning in Medical Education Group (UK CReME Group) with a former colleague and colleagues from Cambridge and Keele medical schools. She is now secretary of the CReME group.
Competing interests: none declared.
References
- Croskerry P. A universal model of diagnostic reasoning. Academic Medicine 2009 84(8):1022–1028.
- Evans J and Over D. Rationality and reasoning. Psychology Press, 1996, Hove.