Clinical reasoning and COVID 19 pandemic: current influencing factors Let us take a step back!
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CE - LETTER TO THE EDITOR
Clinical reasoning and COVID 19 pandemic: current influencing factors Let us take a step back! Marie‑Claude Audétat1,2 · Julia Sader1 · Matteo Coen1,3 Received: 30 June 2020 / Accepted: 24 September 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Caminante, no hay camino, se hace camino al andar. Traveller, there is no path, paths are made by walking. Antonio Machado (free translation)
Clinical reasoning may be defined as “the sum of the thinking and decision-making processes associated with clinical practice (…) it enables practitioners to take “wise” action, making the best-judged action in a specific context” [1]. Although perfectible, these reasoning processes are relatively well established in clinical settings and teams of health care professionals. In the last few weeks, COVID-19 has become the leading cause of hospitalization, morbidity and mortality in most of the world [2]. The fight against this pandemic has shaken up clinical practices, also regarding quality improvement and patient safety. Uncertainties related to the virus itself, influx of patients deteriorating very quickly, the need to develop new ways of working, changes in teams and work schedules, but also stress, fatigue and fear for oneself and for loved ones, are all elements of the context which contribute to influencing clinical reasoning. From then on, in such an uncertain, rapidly changing and potentially anxiety-provoking context, would it not be worthwhile to think about how our clinical reasoning may be impacted? Authors sometimes use the term problem space to reflect these multiple contexts and * Marie‑Claude Audétat Marie‑[email protected] 1
(UDREM) Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
2
(UIGP) Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
3
Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
their specificities. “Problem spaces comprise the immediate clinical problem and task environment of clinical decision making embedded in the interests and frames of references of practitioners and patient” [1]. These problem spaces are part of the broader clinical reasoning context that encompasses the local, organisational, sociocultural and global factors that influence clinical reasoning. Here is a clinical example to illustrate how issues related to these spaces can affect clinical reasoning (Fig. 1). A 70-year-old man consulted for profound fatigue. The patient’s medical history was significant for aortic valve replacement in the past year. The patient was ill looking and highly febrile; physical examination revealed a systolic murmur over the aortic valve area and crackles over the lower lobes of lungs. Laboratory tests showed leucocytosis, and elevated C-reactive protein and venous lactate. ECG and chest X-ray were normal. Two nasal swabs for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tu
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