The last case syndrome

Our decision-making should not be influenced by the most recent event.

My young and enthusiastic apprentice intervened while I was examining the patient thoughtfully. The patient had been troubled by unbearable, atypical pain in the legs. “Sir, this could be COVID-induced vasculitis. Last week, we saw a patient like this,” my junior said. I could not buy it since leg pain from COVID-19 is exceptionally rare. In medical diagnosis, common things are always commoner.

Though there is an eureka feeling when we crack a rare diagnosis, rare diseases are obviously uncommon. When patients present with a constellation of symptoms not fitting into one particular disease pattern, doctors stumble. In such difficult situations, our decision-making is often strongly influenced by the “last case”, which a physician has encountered recently. We term this the “last case syndrome”.

In our practical day-to-day life too, we find ourselves in difficult situations frequently. We have to take a decision on an important issue. Our mind is clouded by many pressing issues and the final decision is many times influenced by our most recent experience on that issue. This could be the road which we need to take to reach a particular destination. Last time, this road was quite busy; so, I will go through the other way.

It could be matters of more serious importance like a key business decision. Should I invest my money in this venture? Recent trends are favouring this business model. The decisive moment could follow after reading our child’s report card. The child has fared poorly in one exam, and we start doubting the quality of the teachers, the school’s standards, the child’s time spent on recreation, sports, and weekends and so on. We wonder, should I transfer him to another school? Should I call off his tennis classes?

We don’t look back at events that had happened over a long period of time. We often decide based on the most recent experience which we had. The childhood friend, who could not offer money in need, the friendly neighbour who walked away without eye contact that morning, the trusted junior colleague who did not turn in the report at the right time, are all quickly judged based on the “last case”.

Form and class

Team selection in sports often fall into this trap. One particular player who performed well in the warm-up match is preferred over a talented player who has hit a recent rough patch. Don’t we agree that form is temporary, but class is permanent? The players’ decisions are also significantly influenced by the last ball or the last over. The batsman premeditatedly walks down the pitch looking for a slow ball based on the last ball. Sports is a mind game as much as it is a physical game. The shrewd player who understands this, plays the ball on merit based on his years of experience and skill and not based on the previous ball alone.

The multi-crore cinema industry is another typical example of this last case syndrome. We are bombarded with movies of one particular genre in a season. Horror comedies suddenly become the rage, influenced by the grand success of one or two movies. Most of these ‘pattern’ movies tragically tank in the box office with millions of rupees going down the drain. We witness waves of gangster movies, romantic comedies, period films and real life stories, coming up in crops and waning later. The decisions are clearly influenced by the success of one particular genre (the last case).

Conventional decisions in medical diagnosis and consequently the treatment are based on multiple factors including evidence documented in medical literature, experience accrued over years of training, and sometimes, the intuition of the physician. Such evidence, experience and shared wisdom with mentors and colleagues often decide the success of a treatment rather than the influence of the last case. In real life situations too, decisions based on a thorough analysis, discussions with peers and elders and conflation of information from multiple previous experiences will be stronger and efficient than momentary ones based on the recent experience.

rishiortho@gmail.com