Cognitive bias and clinical acumen in uveitis practice

Uveitis represents a heterogeneous group of intraocular inflammatory disorders, each characterized by differing etiology, clinical phenotype, and prognosis.1 Many uveitic entities extend far beyond eye-limited inflammation and are closely associated with systemic immune-mediated or infectious diseases. The diagnosis of uveitis often remains difficult in routine clinical practice, with delayed diagnosis and misdiagnosis being frequent and well-recognized challenges. Several factors contribute to these diagnostic challenges. First, uveitis is a relatively uncommon inflammatory eye disease, with a reported population prevalence of approximately 0.1% to 0.3%, meaning that nearly 1 to 3 individuals per 1000 population may be affected.2 The challenge of uveitis management is further compounded by infrequent clinical exposure and limited formal training among ophthalmologists in rare inflammatory eye diseases, often contributing to a prolonged diagnostic and therapeutic odyssey. Second, several uveitic entities may exhibit more than one clinical presentation, and at times, even rare manifestations have been reported. The wide phenotypic variability of these disorders further complicates clinical diagnosis. Although syphilis is classically described as the ‘great masquerader’ in medicine, the list of masquerading disorders in uveitis extends far beyond syphilis alone. Conditions such as ocular tuberculosis, sarcoidosis, and posterior scleritis may each present with a broad and variable spectrum of manifestations, and familiarity with a single ocular phenotype is insufficient to diagnose these entities. Such overlap in presentations within a single clinical entity not only is confusing for ophthalmologists but also often puzzles even experts who have been practicing uveitis for many years. One such example is sarcoidosis, which is primarily known to present as granulomatous uveitis according to the Woods or clinicopathological classification, but can also present as nongranulomatous uveitis.3 Another example is HLA-B27-associated uveitis, which is classically described as unilateral alternating anterior uveitis, but can also present with severe vitritis and other posterior segment involvement. Third, the diagnosis of uveitis is often dynamic and evolving. What initially presents as one phenotype may not remain confined to it over time. Restricting a diagnosis on the basis of the presenting phenotype therefore risks misdiagnosis. Furthermore, several nonuveitic entities may closely mimic uveitic diseases. For example, a serous retinal detachment due to inflammatory pathology must be differentiated from central serous chorioretinopathy (CSCR) as corticosteroid therapy may worsen the disease if CSCR is misdiagnosed as inflammatory pathology. Similarly, intraocular lymphoma may mimic vitritis and may initially respond to corticosteroid therapy without any detectable changes in the central nervous system. Finally, and perhaps most importantly, a significant proportion of uveitic entities are associated with systemic diseases. Accurate characterization of such disorders requires not only expertise in comprehensive ophthalmic examination but also a sound understanding of systemic medicine. Diagnostic error is defined as a failure to reach an accurate and timely explanation of a patient’s health problem.4,5 The terms ‘misdiagnosis’ and ‘delayed diagnosis’ both fall under this umbrella terminology of diagnostic error.5 While evaluating the reasons for misdiagnosis and delayed diagnosis in uveitis, it is important to remember that these errors do not always arise solely from lack of clinical acumen but also from the inherent complexities of uveitic diseases. Clinical acumen may be defined as the application of wisdom in clinical practice to form judgment and arrive at the correct diagnosis. Such wisdom requires repeated practical application before it evolves into clinical skill. Thus, clinical acumen requires practice and practical application, not merely knowledge. In uveitis practice, clinical acumen largely depends on the ability to perform a comprehensive ophthalmic examination and focused history taking. Sir William Osler, the 19th-century physician and one of the four founders of Johns Hopkins Hospital, famously stated, “Listen to your patient; he is telling you the diagnosis.” However, this is often far more difficult than it appears, and history taking therefore remains one of the most important arts in the diagnosis of uveitis. Sir Thomas Lewis, one of the founding fathers of modern cardiology and clinical electrophysiology, remarked that while any house physician could learn to elicit physical signs within a few months, it was the skill of history taking that truly distinguished a good clinician from a poor one.6 Active listening remains one of the most underused communication skills in medicine, and clinicians often pay the price for this while managing cases of uveitis. This is particularly challenging in countries like India, where a single physician often has to manage a very large number of patients. High patient volumes, busy outpatient clinics, and limited consultation time frequently make it difficult to distinguish challenging cases of uveitis from more common ocular diseases. Additionally, there is limited scope for detailed systemic examination in a routine ophthalmic outpatient clinic, and systemic evaluation in uveitis therefore depends largely on careful history taking. Obtaining a reliable history itself can be challenging, especially during the first clinical encounter, and physicians often need to exercise considerable empathy as patients may hesitate to disclose crucial or sensitive information, particularly in societies where social taboos remain strong.7 This perspective brings us to one of the interesting terms used in medicine in recent times: “hyposkillia,” introduced by Herbert L. Fred in his guest editorial, where he defined it as physicians who “cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess the information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly.”8 He highlighted that when clinicians were too quick to treat every patient immediately, they often failed to understand the natural course of disease. He also pointed out that excessive dependence on tests and numerical values gradually shifted the focus away from the patient and toward investigations and laboratory results. Overreliance on investigations and imaging is equally responsible for such behavior, and the same holds true in the practice of uveitis. In the absence of the above-mentioned clinical skills, a positive laboratory result or suggestive ocular imaging finding can hardly make a meaningful difference in the management of uveitis. As a result, one may encounter clinicians treating a positive Mantoux test in the absence of a suggestive clinical phenotype, or treating subretinal fluid on optical coherence tomography with anti-VEGF agents without adequately considering its underlying pathogenesis. Advances in ocular imaging, molecular diagnostics, and laboratory investigations can hardly make a significant impact on the diagnostic accuracy of uveitis in the presence of “hyposkillia.” Broadly, two systems of thinking processes underlie the diagnostic decisions we make in day-to-day clinical practice. The first is intuitive, which is fast, frugal, and pattern-based, while the second is analytical, which is slow, systematic, and planned.9 Often, our best clinical decisions come from a phasewise transition or calibration from the first system to the second. Beyond the disease-related factors outlined above, cognitive biases that are well recognized in general medical practice also contribute meaningfully to diagnostic error in uveitis.10 The first is anchoring bias, which makes the clinician stick to the initial intuitive diagnosis.10 For example, a patient presenting with unilateral painful red eye, photophobia, and anterior chamber reaction may initially be diagnosed as acute anterior uveitis. Once this diagnosis becomes anchored in the clinician’s mind, the posterior segment may not be examined meticulously, leading to missed peripheral retinal necrosis in acute retinal necrosis (ARN). The patient may then receive only topical corticosteroids and cycloplegics, while the underlying herpetic retinitis continues to progress rapidly, potentially resulting in retinal detachment and severe visual loss. In such situations, the diagnostic error does not arise solely from lack of knowledge but from the failure to move beyond the initial intuitive diagnosis despite the possibility of alternative explanations. Premature closure is another common cognitive bias in which the clinician stops considering alternative differentials too early.10–12 This results in early termination of analytical reasoning, with acceptance of a diagnosis before adequately ruling out other possibilities. In every case of uveitis, the clinician must continue asking, “What else could it be?” Because many uveitic entities share similar clinical signs, such cognitive errors can lead to serious consequences. For example, hypopyon uveitis has a broad differential diagnosis, and failure to systematically exclude all possible causes may result in significant diagnostic and therapeutic errors. The danger of premature closure of differentials in uveitis lies in the fact that similar ocular signs may arise from entirely different infectious, inflammatory, or masquerade disorders. Availability bias is another common and interesting cognitive error to which clinicians often fall victim.10,11 Such bias usually arises from recently encountered similar-looking cases, recent literature reading, or discussions during CMEs and scientific meetings.10,11 For example, after recently attending a CME on ocular tuberculosis, a clinician may begin to overattribute all cases of uveitis to tuberculosis despite the absence of sufficient clinical or laboratory evidence supporting the diagnosis. As a result, clinicians may unconsciously overestimate the likelihood of a diagnosis simply because it is fresh in memory. In this context, it is important to mention that evidence-based medicine should serve as an adjunct to clinical judgment, and not as its replacement. Confirmatory bias is another cognitive error, which may simply be described as “falling in love with one’s own diagnosis.” The affected clinician develops a tendency to seek confirmatory evidence supporting the favored diagnosis while subconsciously ignoring contradictory evidence against it, however persuasive such contradictions may be.10,11,13 Last, the most dangerous clinician is not the ignorant one but the one who has stopped questioning himself in the clinic. Overconfidence bias, the tendency to believe one knows more than one actually does, is perhaps the most dangerous of all. Several studies across different branches of medicine have shown that physicians often underestimate the frequency of their own diagnostic errors and overestimate their diagnostic accuracy when asked to self-assess.14 This remains equally applicable to the practice of uveitis, creating one of the most important cognitive blind spots.About the authorProf. Parthopratim Dutta Majumder Prof. Parthopratim Dutta Majumder completed his graduation and post-graduation from Silchar Medical College, Assam University, and pursued his fellowship in Medical Retina and Uvea at Sankara Nethralaya, where he currently serves as Professor and Senior Consultant in the Department of Uvea and Medical Retina. Over the years, he has received several prestigious awards, delivered more than 290 invited lectures at national and international meetings, and authored numerous research articles in various journals. He has also contributed more than 70 chapters to ophthalmology textbooks and edited six books. Recognized for his research impact, he was ranked among the world’s top 2% of scientists in 2024 and 2025 according to Stanford University’s Scientists List. He currently serves as the Secretary of the Uveitis Society of India (USI) and is also a member of the International Uveitis Study Group (IUSG) and the Intraocular Inflammation Society (IOIS). He is actively involved in teaching and academic initiatives and is among the pioneers in India who initiated online ophthalmic teaching resources through the portal www.eophtha.com since 2008.