The clinician's thought block

Peak summer, or kathiri veyil as we refer to it in Tamil, has passed. Some uncharacteristic mild rains have also started drizzling in Chennai. But the ambient temperature and humidity continue to be oppressive. On most clinic days, this becomes an important factor in governing the mood of the day. I have been feeling a lot more irritable the past few months, especially during the start of the clinic. Slowly the body gets used to the sweltering ambient conditions and things become better as the day progresses! This irritability manifests itself as long gaps in the flow of thought, or thought blocks. A middle aged woman came the other day with complaints of intense itching all over the body. There was no rash. She does not have diabetes or hypertension. On a pleasant day my mind would have gone through a whole list of differential diagnoses for itching without rashes - liver disease, kidney disease, anemia, worm infestation, thyroid dysfunction, or sometimes even cancers. But that day, I was blank for a full minute. A minute of blocked thought when a patient is seated in front of you, is a LONG time. I did not know what questions to ask her, what physical indicators I should look for, or even what tests I should order. I am sure she noticed that I am blank, because there was an awkward silence in the room. I gathered myself up and sat upright. One thing I do when I have such blocks is to spell out my thoughts aloud. I re-stated her complaints, “So, you are having itching all over the body. It is preventing you from sleeping. You don’t have any rashes anywhere. You also do not have diabetes or high BP. Am I right?” I stated all this and she nodded. It was a savior, because that got my thought process running and I found that she was looking very pale. So, I ordered a blood test to check her hemoglobin. We found that she was severely anemic and started her on iron.  I also gave her some symptom relief with tablets to control her itching sensation. A clinician’s thought block is tough. I am quite certain many others also go through such thought blocks. Interestingly I have never discussed about ‘clinician’s thought block’ with anyone so far, or strategies to overcome such a thought block. 

 

As a young trainee doctor working with great clinicians like Dr. K.P. Misra, Dr. Arjun, Dr. Usha, Dr. Bennet, Dr. Pari, I have never seen them fumbling or struggling for the right words or actions during their interactions with patients. They all exemplified confidence and competence in their work. They seemed to know what exactly must be done for the patient. I have closely observed them work and wondered if the diagnostic and treatment algorithms are embedded in their brains. As a wide-eyed medical student, I would look at their face when they interact with their patients and would see the click of recognition of a tell-tale symptom, or a classic clinical finding and at that point it would look like a secret lock in their embedded algorithm would open and the thought would flow smoothly to the next steps in the management of the patient. 

 

Throughout the training period, I have always had blank spaces in my diagnostic and clinical reasoning. I used to attribute it to immaturity, lack of knowledge and lack of experience and I largely think that was correct. I am now just a few years younger than my teachers when I first met them. The blanks have reduced to a significant extent, but I am still stymied on a frequent basis by chasms in my thinking process. Now I wonder if this was true for my teachers as well. Did they also have such thought blocks when sitting in front of a patient? How did they handle these thought blocks? Do all clinicians face them? 

Psychology literature says that thought blocks are usually the consequence of information overload. I had a 65-year-old patient who came to me with a thick medical file a few months ago. He has diabetes, hypertension, heart disease, suffered a stroke a few years ago, developed kidney disease, has multiple hormonal problems and had developed a painful and infected swelling over the upper back. He came to me for the treatment of the swelling, which I diagnosed as a carbuncle (a pus filled swelling due to a bacterial infection of the skin). But there were so many clinical variables to consider before draining the pus and starting treatment that my brain froze for a few minutes before I could decide on the next steps. 

 

Sometimes severe thought block happens when a new clinical clue completely derails the diagnostic anchor and leads us in a new direction. A diagnostic anchor is a biased diagnosis to which the clinician is anchored based on one set of findings, not considering other possibilities. Two weeks ago, a young man came to me with a painful rash in his genital area. He is a thin built guy, otherwise healthy and fit. There were pain, redness, cracks and swelling in the genital region. In an otherwise healthy young man, such painful sores in the genitals are indicative of a sexually transmitted infection. So, I went along that line of inquiry and testing and treating. He kept reporting to me that the rash is persistent and painful. I reassured him and requested him to complete the full course of treatment. He came back after almost a week with the rashes still persistent and now a whitish pasty discharge had started. The discharge gave a clue that this could be a fungal (candidiasis) infection. That triggered a thought process whether this could be diabetes related, and I tested him and found that he had very high blood sugar levels. My brain froze because my previous diagnostic anchor of a sexually transmitted infection was wrong and it turned out to be diabetes related candidiasis. 

 

One of the commonest causes for frozen thought process is fatigue, both physical fatigue and emotional fatigue. Moral fatigue also brings us to a thought block. I experience the latter very frequently. Mrs. S has been my patient for a long time.  She has poorly controlled diabetes. The unique thing about chronic lifestyle diseases like diabetes is that the treatment is life-long and patients must change and adapt their lifestyles to suit the disease. Therefore, clinical management plays a small role, but a major role is played by self-management by the patient. As a conscientious clinician, all we can do is ensure that the patient has all the information, resources and support that they need to self-manage their condition. While I do my best to provide this, a lot depends on how patients handle their self-management. Mrs. S had very poorly controlled sugars, despite the best of my efforts. So, I was constantly struggling titrating her drug doses, running additional tests and breaking my head over how to bring her blood sugars to target levels. Patients like Mrs. S, who are ‘difficult’ leave a deep impact on the emotional wellbeing of the clinician. We have a constant nagging feeling about how to help them. One day, I learned from her son that Mrs. S has not been following any of my advice and is simultaneously consulting a complementary and alternative medicine expert and taking medicines from there. I felt cheated, used and disappointed. It led me into a state of moral fatigue. My inner morality was struggling to accept the conflict between my efforts to do what is right by Mrs. S and her deceit in making me believe that my efforts were in vain. This is not uncommon. Often these are not intentional actions by patients. They often do not realize the efforts that go into thinking through and arriving at a treatment plan. For them it is like choosing to buy one mobile, and then changing the mind and buying another one. But when such moral fatigue happens, my brain goes into a freeze. The other thing that happens in the aftermath of such moral fatigue is a hyper-vigilant state of mistrust that lingers in the mind for quite some time. On the day that the whole Mrs. S moral fatigue fiasco happened, there was another patient who came. Her last visit was on 14.04.2026 and she had come two months later 20.06.2026. She had missed a month’s tablets because the previous visit I had given her only 1 month’s prescription. I started talking to her and counseling her about not missing tablets, taking them regularly, importance of keeping blood sugars under control and so on. She kept repeating that she never missed even one day’s medicine. I told her “I don’t believe you. My case reports don’t lie. Look at when you came last. You came 2 months ago and bought 1 month’s prescription refill” She still denied that she missed even a day’s tablets. She kept saying she came to the clinic last month. I completely lost my patience and called the medical records staff and asked her to explain things to the patient. She came and verified her register and said that the patient had in fact come on 14.05.2026 and not 14.04.2026 as recorded in the case record. It was a mistaken date entered in the case record. I felt embarrassed for creating such a big scene. The patient had been telling me the truth. But I was so hyper-vigilant after ‘being deceived’ by Mrs. S that I refused to believe her. 

 

Thought blocks are a silent psychological crisis for the clinician. When I encounter these blocks, I feel incompetent and start losing my confidence. This is largely because of my ideas of the competence and brilliance of my role models and my acute sense of failure to keep up to their level of efficiency. Thought blocks make me feel extremely vulnerable for those few minutes. It exposes a raw human vulnerability in me, which I carefully keep guarded behind a rock-solid façade of knowledge and competence. As a primary care physician working in a rural clinic, already it is a very lonely job. On most days there are no professional peers to bounce ideas off. There are no daily interactions with doctors to exchange knowledge or thoughts. In such a lonely enterprise, thought blocks make me feel even more lonely. I have noticed it also impacts on the doctor-patient relationship. Being clueless, expressing it on the face and the body language, can lead to mistrust. The anxiety that I feel during these phases of thought block can also be transferred to the patient and lead to a situation of mutual anxiety. There have been innumerable occasions when patients have told me about the uncertainty and confusion that they have perceived in their “other doctor” because of which they left that doctor and came to me. I am certain that my thought blocks and lack of confidence makes them leave me and talk about me to some other doctor. 

 

Over the years, I have learned some strategies to handle my thought blocks when I face them. I externalize my thoughts, verbalize them loudly to the patient in the form of confirmation. I restate their symptoms to them. I explain the findings of my clinical examination. This give me the sense of discussing the ‘case’ with another clinician and kick starts my blocked thought. Sometimes I make a “problem list” in the patient’s case record and write down detailed notes. I tell the patient, “please give me some time to put down my thoughts and organize them” and let them know that I am working and thinking about them. Sometimes, I pick up my phone, as though it is an important call, excuse myself, and walk out of the room for a minute and close my eyes and take a few deep breaths. The change in scene, and the deep breathing helps kick start my thoughts. Despite all this, a serious thought block in front of a patient is a nightmare. I have learned that thought blocks are not signs of incompetence or failure. They are inevitable, authentic manifestations of the cognitive limits of the clinician’s mind.