Introduction: Initially regarded as a type of influenza, COVID-19 was later identified as a severe acute respiratory syndrome. However, it soon became evident that COVID-19 was more than just a lung infection and that it was a disease with an increasing number of non-respiratory consequences, such as neurological and vascular issues, as well as clinical manifestations. Clinicians were abruptly faced with a difficult, hazardous, and unusual disease for which they lacked a well-defined and organized clinical script. We aimed to deepen and understand how the COVID-19 illness script was being constructed during the early stage of the pandemic. Methods: The study population consisted of residents, chief residents, and attending physicians from different departments. Two focus groups and a one-to-one semi-structured encounter were conducted. The researchers closely analysed the data to identify common themes—topics, ideas and patterns of meaning that come up repeatedly. The transcripts were then thematically analysed using both deductive and inductive methods. Results: Two major themes emerged from the qualitative analysis: 1) unsettled conditions of learning, and 2) successive steps and content of script building. Our findings demonstrate the challenging situation that doctors faced in an extremely uncertain environment without any prior knowledge to fall back on. Conclusion and Discussion: Clinicians have had to undergo awful levels of pressure as a result of the COVID-19 pandemic, and they have had to rewrite their illness scripts to account for this atypical context. We uncovered several main factors that were essential in script construction: clinical reasoning and decision making in an emotional context and stressful conditions, unsettled learning processes, and perturbed supervision. In this perspective, the COVID-19 pandemic offers a unique opportunity to examine how an unprecedented constellation of contextual factors may impact the processes and performance of clinical reasoning. Crises are characterized as situations that put institutions in jeopardy of failing, exposing their flaws and strengths and occasionally resulting in institutional change. Therefore, this pandemic gives the opportunity to review how to supervise and teach uncertainty, as well as to emphasize the value of patient communication in the process of the construction of illness scripts.
References
[1]
Lubarsky, S., Dory, V., Audétat, M., Custers, E. and Charlin, B. (2015) Using Script Theory to Cultivate Illness Script Formation and Clinical Reasoning in Health Professions Education. Canadian Medical Education Journal, 6, e61-e70. https://doi.org/10.36834/cmej.36631
[2]
Elstein, A., Shulman, L. and Sprafka, S. (1978) Medical Problem Solving: An Analysis of Clinical Reasoning. Harvard University Press.
[3]
Feltovich, P. and Barrows, H. (1984) Issues of Generality in Medical Problem Solving. In: Schmidt, H.G. and De Volder, M.L., Eds., Tutorials in Problem-Based Learning: A New Direction in Teaching the Health Professions, Van Gorcum, 255.
[4]
Charlin, B., Tardif, J. and Boshuizen, H.P.A. (2000) Scripts and Medical Diagnostic Knowledge: Theory and Applications for Clinical Reasoning Instruction and Research. Academic Medicine, 75, 182-190. https://doi.org/10.1097/00001888-200002000-00020
[5]
Lubarsky, S., Charlin, B., Cook, D.A., Chalk, C. and van der Vleuten, C. (2011) Script Concordance Testing: A Review of Published Validity Evidence. Medical Education, 45, 329-338. https://doi.org/10.1111/j.1365-2923.2010.03863.x
[6]
Keemink, Y., Custers, E.J.F.M., van Dijk, S. and ten Cate, O. (2018) Illness Script Development in Pre-Clinical Education through Case-Based Clinical Reasoning Training. International Journal of Medical Education, 9, 35-41. https://doi.org/10.5116/ijme.5a5b.24a9
[7]
Feltovich, P. (1983) Expertise: Reorganizing and Refining Knowledge for Use. Professions Education Research Notes, 4, 5-7.
[8]
Nelson, K. (1993) Events, Narratives, Memory: What Develops. In: Nelson, C.A., Ed., Memory and Affect in Development: The Minnesota Symposia on Child Psychology, Erlbaum, 288.
[9]
Monteiro, S.M. and Norman, G. (2013) Diagnostic Reasoning: Where We’ve Been, Where We’re Going. Teaching and Learning in Medicine, 25, S26-S32. https://doi.org/10.1080/10401334.2013.842911
[10]
Schmidt, H. and Rikers, R. (2007) How Expertise Develops in Medicine: Knowledge Encapsulation and Illness Script Formation. Medical Education, 41, 1133-1139.
[11]
Schmidt, H.G., Norman, G.R. and Boshuizen, H.P. (1990) A Cognitive Perspective on Medical Expertise: Theory and Implications. Academic Medicine, 65, 611-621. https://doi.org/10.1097/00001888-199010000-00001
[12]
Charlin, B., Boshuizen, H.P.A., Custers, E.J. and Feltovich, P.J. (2007) Scripts and Clinical Reasoning. Medical Education, 41, 1178-1184. https://doi.org/10.1111/j.1365-2923.2007.02924.x
[13]
Custers, E.J.F.M. (2014) Thirty Years of Illness Scripts: Theoretical Origins and Practical Applications. Medical Teacher, 37, 457-462. https://doi.org/10.3109/0142159x.2014.956052
[14]
Eva, K., Brooks, L. and Norman, G. (1998) Is Online Reasoning Equivalent to Post-Hoc Explaining? 109th Annual Meeting of the Association of American Medical Colleges, New Orleans, November 1998.
[15]
Nendaz, M.R., et al. (2005) Clinical Reasoning: From Research Findings to Applications for Teaching. PedMed, 6, 235-254.
[16]
Norman, G. (2009) Dual processing and diagnostic errors. Advances in Health Sciences Education, 14, 37-49. https://doi.org/10.1007/s10459-009-9179-x
[17]
Rikers, R.M.J.P., Schmidt, H.G., Boshuizen, H.P.A., Linssen, G.C.M., Wesseling, G. and Paas, F.G.W.C. (2002) The Robustness of Medical Expertise: Clinical Case Processing by Medical Experts and Subexperts. The American Journal of Psychology, 115, 609-629. https://doi.org/10.2307/1423529
[18]
Sadeghi, A., Ali Asgari, A., Namazi, H. and Adibi, P. (2021) Clinical Reasoning during the COVID-19 Pandemic. Journal of Research in Medical Sciences, 26, 65. https://doi.org/10.4103/jrms.jrms_1008_20
[19]
Hay-David, A.G.C., Herron, J.B.T., Gilling, P., Miller, A. and Brennan, P.A. (2020) Reducing Medical Error during a Pandemic. British Journal of Oral and Maxillofacial Surgery, 58, 581-584. https://doi.org/10.1016/j.bjoms.2020.04.003
[20]
Coen, M., Sader, J., Junod-Perron, N., Audétat, M. and Nendaz, M. (2022) Clinical Reasoning in Dire Times. Analysis of Cognitive Biases in Clinical Cases during the COVID-19 Pandemic. Internal and Emergency Medicine, 17, 979-988. https://doi.org/10.1007/s11739-021-02884-9
[21]
Boyle, J.G., Walters, M.R., Jamieson, S. and Durning, S.J. (2020) Clinical Reasoning in the Wild: Premature Closure during the COVID-19 Pandemic. Diagnosis, 7, 177-179. https://doi.org/10.1515/dx-2020-0061
[22]
Suri, H. (2011) Purposeful Sampling in Qualitative Research Synthesis. Qualitative Research Journal, 11, 63-75. https://doi.org/10.3316/qrj1102063
[23]
Coyne, I.T. (1997) Sampling in Qualitative Research. Purposeful and Theoretical Sampling; Merging or Clear Boundaries? Journal of Advanced Nursing, 26, 623-630. https://doi.org/10.1046/j.1365-2648.1997.t01-25-00999.x
[24]
Krueger, R. and Casey, M. (2000) Focus Groups: A Practical Guide for Applied Research. 3rd Edition, Sage Publication.
[25]
Kiger, M.E. and Varpio, L. (2020) Thematic Analysis of Qualitative Data: AMEE Guide No. 131. Medical Teacher, 42, 846-854. https://doi.org/10.1080/0142159x.2020.1755030
[26]
Braun, V. and Clarke, V. (2006) Using Thematic Analysis in Psychology. Qualitative Research in Psychology, 3, 77-101. https://doi.org/10.1191/1478088706qp063oa
[27]
Charlin, B., Tardif, J. and Boshuizen, H.P.A. (2000) Scripts and Medical Diagnostic Knowledge: Theory and Applications for Clinical Reasoning Instruction and Research. Academic Medicine, 75, 182-190. https://doi.org/10.1097/00001888-200002000-00020
[28]
Bordage, G. and Lemieux, M. (1986) Some Cognitive Characteristics of Medical Students with and without Diagnostic Reasoning Difficulties. Research in Medical Education, 25, 185-190.
[29]
Bordage, G. and Lemieux, M. (1991) Semantic Structures and Diagnostic Thinking of Experts and Novices. Academic Medicine, 66, S70-S72. https://doi.org/10.1097/00001888-199109000-00045
[30]
Durning, S.J., Costanzo, M.E., Artino, A.R., Graner, J., van der Vleuten, C., Beckman, T.J., et al. (2015) Neural Basis of Nonanalytical Reasoning Expertise during Clinical Evaluation. Brain and Behavior, 5, e00309. https://doi.org/10.1002/brb3.309
[31]
Stevens, F.L., Hurley, R.A. and Taber, K.H. (2011) Anterior Cingulate Cortex: Unique Role in Cognition and Emotion. The Journal of Neuropsychiatry and Clinical Neurosciences, 23, 121-125. https://doi.org/10.1176/jnp.23.2.jnp121
[32]
Schmidt, H.G. and Boshuizen, H.P.A. (1993) On Acquiring Expertise in Medicine. Educational Psychology Review, 5, 205-221. https://doi.org/10.1007/bf01323044
[33]
Eva, K.W., Hatala, R.M., LeBlanc, V.R. and Brooks, L.R. (2007) Teaching from the Clinical Reasoning Literature: Combined Reasoning Strategies Help Novice Diagnosticians Overcome Misleading Information. Medical Education, 41, 1152-1158. https://doi.org/10.1111/j.1365-2923.2007.02923.x
[34]
Pelaccia, T., Tardif, J., Triby, E. and Charlin, B. (2011) An Analysis of Clinical Reasoning through a Recent and Comprehensive Approach: The Dual-Process Theory. Medical Education Online, 16, Article ID: 5890. https://doi.org/10.3402/meo.v16i0.5890
[35]
Norman, G. (2005) Research in Clinical Reasoning: Past History and Current Trends. Medical Education, 39, 418-427. https://doi.org/10.1111/j.1365-2929.2005.02127.x
[36]
Charlin, B., Lubarsky, S., Millette, B., Crevier, F., Audétat, M., Charbonneau, A., et al. (2012) Clinical Reasoning Processes: Unravelling Complexity through Graphical Representation. Medical Education, 46, 454-463. https://doi.org/10.1111/j.1365-2923.2012.04242.x
[37]
Epstein, S. (1994) Integration of the Cognitive and the Psychodynamic Unconscious. American Psychologist, 49, 709-724. https://doi.org/10.1037/0003-066x.49.8.709
[38]
Hogarth, R.M. (2005) Deciding Analytically or Trusting Your Intuition? The Advantages and Disadvantages of Analytic and Intuitive Thought, in the Routines of Decision Making. Lawrence Erlbaum Associates Publishers, 67-82.
[39]
Kahneman, D. (2003) A Perspective on Judgment and Choice: Mapping Bounded Rationality. American Psychologist, 58, 697-720. https://doi.org/10.1037/0003-066x.58.9.697
[40]
Marcum, J.A. (2012) An Integrated Model of Clinical Reasoning: Dual-Process Theory of Cognition and Metacognition. Journal of Evaluation in Clinical Practice, 18, 954-961. https://doi.org/10.1111/j.1365-2753.2012.01900.x
[41]
Croskerry, P. (2009) A Universal Model of Diagnostic Reasoning. Academic Medicine, 84, 1022-1028. https://doi.org/10.1097/acm.0b013e3181ace703
[42]
Kozlowski, D., Hutchinson, M., Hurley, J., Rowley, J. and Sutherland, J. (2017) The Role of Emotion in Clinical Decision Making: An Integrative Literature Review. BMC Medical Education, 17, Article No. 255. https://doi.org/10.1186/s12909-017-1089-7
[43]
Heyhoe, J., Birks, Y., Harrison, R., O’Hara, J.K., Cracknell, A. and Lawton, R. (2015) The Role of Emotion in Patient Safety: Are We Brave Enough to Scratch beneath the Surface? Journal of the Royal Society of Medicine, 109, 52-58. https://doi.org/10.1177/0141076815620614
[44]
Garfinkel, S.N., Zorab, E., Navaratnam, N., Engels, M., Mallorquí-Bagué, N., Minati, L., et al. (2015) Anger in Brain and Body: The Neural and Physiological Perturbation of Decision-Making by Emotion. Social Cognitive and Affective Neuroscience, 11, 150-158. https://doi.org/10.1093/scan/nsv099
[45]
Kusev, P., Purser, H., Heilman, R., Cooke, A.J., Van Schaik, P., Baranova, V., et al. (2017) Understanding Risky Behavior: The Influence of Cognitive, Emotional and Hormonal Factors on Decision-Making under Risk. Frontiers in Psychology, 8, Article 102. https://doi.org/10.3389/fpsyg.2017.00102
[46]
Novick, R.J., Lingard, L. and Cristancho, S.M. (2015) The Call, the Save, and the Threat: Understanding Expert Help-Seeking Behavior during Nonroutine Operative Scenarios. Journal of Surgical Education, 72, 302-309. https://doi.org/10.1016/j.jsurg.2014.09.009
[47]
McAndrew, N.S. and Leske, J.S. (2014) A Balancing Act: Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units. Clinical Nursing Research, 24, 357-374. https://doi.org/10.1177/1054773814533791
[48]
Tallentire, V.R., Smith, S.E., Skinner, J. and Cameron, H.S. (2011) Understanding the Behaviour of Newly Qualified Doctors in Acute Care Contexts. Medical Education, 45, 995-1005. https://doi.org/10.1111/j.1365-2923.2011.04024.x
[49]
Islam, R., Weir, C.R., Jones, M., Del Fiol, G. and Samore, M.H. (2015) Understanding Complex Clinical Reasoning in Infectious Diseases for Improving Clinical Decision Support Design. BMC Medical Informatics and Decision Making, 15, Article No. 101. https://doi.org/10.1186/s12911-015-0221-z
[50]
Lazarus, R.S. and Folkman, S. (1984) Stress, Appraisal, and Coping. Springer.
[51]
Morgantini, L.A., Naha, U., Wang, H., Francavilla, S., Acar, Ö., Flores, J.M., et al. (2020) Factors Contributing to Healthcare Professional Burnout during the COVID-19 Pandemic: A Rapid Turnaround Global Survey. PLOS ONE, 15, e0238217. https://doi.org/10.1371/journal.pone.0238217
[52]
de Wit, K., Mercuri, M., Wallner, C., Clayton, N., Archambault, P., Ritchie, K., et al. (2020) Canadian Emergency Physician Psychological Distress and Burnout during the First 10 Weeks of COVID‐19: A Mixed‐methods Study. JACEP Open, 1, 1030-1038. https://doi.org/10.1002/emp2.12225
[53]
Parsons Leigh, J., Kemp, L.G., de Grood, C., Brundin-Mather, R., Stelfox, H.T., Ng-Kamstra, J.S., et al. (2021) A Qualitative Study of Physician Perceptions and Experiences of Caring for Critically Ill Patients in the Context of Resource Strain during the First Wave of the COVID-19 Pandemic. BMC Health Services Research, 21, Article No. 374. https://doi.org/10.1186/s12913-021-06393-5
[54]
Shanafelt, T., Ripp, J. and Trockel, M. (2020) Understanding and Addressing Sources of Anxiety among Health Care Professionals during the COVID-19 Pandemic. JAMA, 323, 2133-2134. https://doi.org/10.1001/jama.2020.5893
[55]
Juvet, T.M., Corbaz-Kurth, S., Roos, P., Benzakour, L., Cereghetti, S., Moullec, G., et al. (2021) Adapting to the Unexpected: Problematic Work Situations and Resilience Strategies in Healthcare Institutions during the COVID-19 Pandemic’s First Wave. Safety Science, 139, Article ID: 105277. https://doi.org/10.1016/j.ssci.2021.105277
[56]
Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., et al. (2020) Factors Associated with Mental Health Outcomes among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Network Open, 3, e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976
[57]
Coen, M., Sader, J., Junod-Perron, N., Audétat, M. and Nendaz, M. (2022) Clinical Reasoning in Dire Times. Analysis of Cognitive Biases in Clinical Cases during the COVID-19 Pandemic. Internal and Emergency Medicine, 17, 979-988. https://doi.org/10.1007/s11739-021-02884-9
[58]
Pottier, P., Dejoie, T., Hardouin, J.B., Le Loupp, A.G., Planchon, B., Bonnaud, A., et al. (2013) Effect of Stress on Clinical Reasoning during Simulated Ambulatory Consultations. Medical Teacher, 35, 472-480. https://doi.org/10.3109/0142159x.2013.774336
[59]
Ghosh, A.K. (2004) On the Challenges of Using Evidence-Based Information: The Role of Clinical Uncertainty. Journal of Laboratory and Clinical Medicine, 144, 60-64. https://doi.org/10.1016/j.lab.2004.05.013
[60]
Wakeham, J. (2015) Uncertainty: History of the Concept. In: Wright, J.D., Ed., International Encyclopedia of the Social & Behavioral Sciences, Elsevier, 716-721. https://doi.org/10.1016/b978-0-08-097086-8.03175-5
[61]
Dhawale, T., Steuten, L.M. and Deeg, H.J. (2017) Uncertainty of Physicians and Patients in Medical Decision Making. Biology of Blood and Marrow Transplantation, 23, 865-869. https://doi.org/10.1016/j.bbmt.2017.03.013
[62]
Han, P.K.J., Klein, W.M.P. and Arora, N.K. (2011) Varieties of Uncertainty in Health Care: A Conceptual Taxonomy. Medical Decision Making, 31, 828-838. https://doi.org/10.1177/0272989x11393976
[63]
Iannello, P., Mottini, A., Tirelli, S., Riva, S. and Antonietti, A. (2017) Ambiguity and Uncertainty Tolerance, Need for Cognition, and Their Association with Stress. A Study among Italian Practicing Physicians. Medical Education Online, 22, Article ID: 1270009. https://doi.org/10.1080/10872981.2016.1270009
[64]
Ramani, D., Soh, M., Merkebu, J., Durning, S.J., Battista, A., McBee, E., et al. (2020) Examining the Patterns of Uncertainty across Clinical Reasoning Tasks: Effects of Contextual Factors on the Clinical Reasoning Process. Diagnosis, 7, 299-305. https://doi.org/10.1515/dx-2020-0019
[65]
Durning, S.J., Artino, A.R., Boulet, J.R., Dorrance, K., van der Vleuten, C. and Schuwirth, L. (2011) The Impact of Selected Contextual Factors on Experts’ Clinical Reasoning Performance (Does Context Impact Clinical Reasoning Performance in Experts?). Advances in Health Sciences Education, 17, 65-79. https://doi.org/10.1007/s10459-011-9294-3
[66]
Ratcliffe, T.A., McBee, E., Schuwirth, L., Picho, K., van der Vleuten, C.P.M., Artino, A.R., et al. (2017) Exploring Implications of Context Specificity and Cognitive Load in Residents. MedEdPublish, 6, 48. https://doi.org/10.15694/mep.2017.000048
[67]
McBee, E., Ratcliffe, T., Picho, K., Artino, A.R., Schuwirth, L., Kelly, W., et al. (2015) Consequences of Contextual Factors on Clinical Reasoning in Resident Physicians. Advances in Health Sciences Education, 20, 1225-1236. https://doi.org/10.1007/s10459-015-9597-x
[68]
Nevalainen, M., et al. (2012) Tolerance of Uncertainty and Fears of Making Mistakes among Fifth-Year Medical Students. Family Medicine, 44, 240-246.
[69]
Guenter, D., Fowler, N. and Lee, L. (2011) Clinical Uncertainty: Helping Our Learners. Canadian Family Physician, 57, 120-125.
[70]
Fox, R. (2000) Medical Uncertainty Revisited. In: Albrecht, G.L., Fitzpatrick, R. and Scrimshaw, S.C., Eds., Handbook of Social Studies in Health and Medicine, Sage, 409.
[71]
Martin, P., Kumar, S., Tian, E., Argus, G., Kondalsamy-Chennakesavan, S., Lizarondo, L., et al. (2022) Rebooting Effective Clinical Supervision Practices to Support Healthcare Workers through and Following the COVID-19 Pandemic. International Journal for Quality in Health Care, 34, mzac030. https://doi.org/10.1093/intqhc/mzac030
[72]
Audétat, M., Laurin, S., Dory, V., Charlin, B. and Nendaz, M.R. (2017) Diagnosis and Management of Clinical Reasoning Difficulties: Part I. Clinical Reasoning Supervision and Educational Diagnosis. Medical Teacher, 39, 792-796. https://doi.org/10.1080/0142159x.2017.1331033
[73]
Martin, P., Tian, E., Kumar, S. and Lizarondo, L. (2022) A Rapid Review of the Impact of COVID‐19 on Clinical Supervision Practices of Healthcare Workers and Students in Healthcare Settings. Journal of Advanced Nursing, 78, 3531-3539. https://doi.org/10.1111/jan.15360
[74]
Moulder, G., Harris, E. and Santhosh, L. (2022) Teaching the Science of Uncertainty. Diagnosis, 10, 13-18. https://doi.org/10.1515/dx-2022-0045
[75]
Wolpaw, T., Papp, K.K. and Bordage, G. (2009) Using SNAPPS to Facilitate the Expression of Clinical Reasoning and Uncertainties: A Randomized Comparison Group Trial. Academic Medicine, 84, 517-524. https://doi.org/10.1097/acm.0b013e31819a8cbf
[76]
Santhosh, L., Rojas, J.C., Garcia, B., Thomashow, M. and Lyons, P.G. (2022) Cocreating the ICU-PAUSE Tool for Intensive Care Unit-Ward Transitions. ATS Scholar, 3, 312-323. https://doi.org/10.34197/ats-scholar.2021-0135in
[77]
Moulton, C.E., Regehr, G., Mylopoulos, M. and MacRae, H.M. (2007) Slowing down When You Should: A New Model of Expert Judgment. Academic Medicine, 82, S109-S116. https://doi.org/10.1097/acm.0b013e3181405a76
[78]
Stewart, M. (2001) Towards a Global Definition of Patient Centred Care. BMJ, 322, 444-445. https://doi.org/10.1136/bmj.322.7284.444
[79]
Seaburn, D.B., Morse, D., McDaniel, S.H., Beckman, H., Silberman, J. and Epstein, R. (2005) Physician Responses to Ambiguous Patient Symptoms. Journal of General Internal Medicine, 20, 525-530. https://doi.org/10.1111/j.1525-1497.2005.0093.x
[80]
Stewart, M., et al. (2000) The Impact of Patient-Centered Care on Outcomes. The Journal of Family Practice, 49, 796-804.
[81]
Rencic, J., Schuwirth, L.W.T., Gruppen, L.D. and Durning, S.J. (2020) Clinical Reasoning Performance Assessment: Using Situated Cognition Theory as a Conceptual Framework. Diagnosis, 7, 241-249. https://doi.org/10.1515/dx-2019-0051
[82]
Brown, J.S., Collins, A. and Duguid, P. (1989) Situated Cognition and the Culture of Learning. Educational Researcher, 18, 32-42. https://doi.org/10.3102/0013189x018001032
[83]
Torre, D., Durning, S.J., Rencic, J., Lang, V., Holmboe, E. and Daniel, M. (2020) Widening the Lens on Teaching and Assessing Clinical Reasoning: From “in the Head” to “Out in the World”. Diagnosis, 7, 181-190. https://doi.org/10.1515/dx-2019-0098
[84]
Kingston, C. and Caballero, G. (2009) Comparing Theories of Institutional Change. Journal of Institutional Economics, 5, 151-180. https://doi.org/10.1017/s1744137409001283
[85]
Lee, C., Lai, H., Lee, C., Chen, M. and Yau, S. (2024) Collaborative Clinical Reasoning: A Scoping Review. PeerJ, 12, e17042. https://doi.org/10.7717/peerj.17042
