Is uncertainty tolerance an epiphenomenon?

Expert patient and general practitioners' perspectives on the clinical attributes needed to deal with uncertainty: a qualitative study

Introduction Clinical uncertainty is not uncommon; however, the current conception of the professional clinician has meant that discussion on uncertainty has focused on elimination rather than recognition. Uncertainty comes from an imbalance in knowledge, data, clinical experience, evidence-based guidelines, judgement, and decision-making. There is a strong argument for improving tolerance of clinical uncertainty, particularly in primary care where general practitioners might be especially vulnerable to uncertainty due to their exposure to undifferentiated illness. Aim This research aims to establish expert patient and general practitioners' perspectives on the clinical attributes needed to deal with uncertainty. Methods Two focus groups, consisting of three general practitioners and five expert patients, discussed uncertainty regarding restless legs syndrome. This topic was used as a rhetorical proxy to examine expert patient and general practitioner perspectives on the clinical attributes needed to deal with uncertainty. The qualitative data were then analysed to form overarching thematic areas. Results Four overarching professional attributes were identified: collaboration, compassion, insight, and unconventional thinking. These are all attributes that lie within a clinician's skillset, but the evidence here suggests that they need to be foregrounded in practice. Discussion In attempting to assess professional clinical practice in relation to uncertainty, this research recommends that clinicians work to adopt a holistic, patient-centred approach, where they explicitly share uncertainties, focus on a patient's emotional state during the diagnostic phases of treatment, and see the merits of challenging themselves to look beyond routine algorithms.

Is emergency doctors' tolerance of clinical uncertainty on a novel measure associated with doctor well-being, healthcare resource use and patient outcomes?

INTRODUCTION

Emergency doctors routinely face uncertainty-they work with limited patient information, under tight time constraints and receive minimal post-discharge feedback. While higher uncertainty tolerance (UT) among staff is linked with reduced resource use and improved well-being in various specialties, its impact in emergency settings is underexplored. We aimed to develop a UT measure and assess associations with doctor-related factors (eg, experience), patient outcomes (eg, reattendance) and resource use (eg, episode costs).

METHODS

From May 2021 to February 2022, emergency doctors (specialty trainee 3 and above) from five Yorkshire (UK) departments completed an online questionnaire. This included a novel UT measure-an adapted Physicians' Reaction to Uncertainty scale collaboratively modified within our team according to Hillen et al's (2017) UT model. The questionnaire also included well-being-related measures (eg, Brief Resilience Scale) and assessed factors like doctors' seniority. Patient encounters involving prespecified 'uncertainty-inducing' problems (eg, headache) were analysed. Multilevel regression explored associations between doctor-level factors, resource use and patient outcomes.

RESULTS

39 doctors were matched with 384 patients. The UT measure demonstrated high reliability (Cronbach's α=0.92) and higher UT was significantly associated with better psychological well-being including greater resilience (Pearson's r=0.56; 95% CI=0.30 to 0.74) and lower burnout (eg, Cohen's d=-2.98; -4.62 to -1.33; mean UT difference for 'no' vs 'moderate/high' burnout). UT was not significantly associated with resource use (eg, episode costs: β=-0.07; -0.32 to 0.18) or patient outcomes including 30-day readmission (eg, OR=0.82; 0.28 to 2.35).

CONCLUSIONS

We developed a reliable UT measure for emergency medicine. While higher UT was linked to doctor well-being, its impact on resource use and patient outcomes remains unclear. Further measure validation and additional research including intervention trials are necessary to confirm these findings and explore the implications of UT in emergency practice.

'I was uncertain, but I was acting on it': A longitudinal qualitative study of medical students' responses to uncertainty

PURPOSE

Uncertainty is ubiquitous within medical practice. Accordingly, how individuals respond to uncertainty, termed uncertainty tolerance (UT), is increasingly considered a medical graduate competency. Despite this, aspects of the UT construct are debated, which may relate to research focused on measuring UT, rather than understanding students' experiences. Therefore, we asked (1) how do medical students describe their responses to uncertainty, (2) how (if at all) do described responses change over time and (3) how do described responses contribute to understanding the UT construct.

METHODS

Engaging an interpretivist worldview, we conducted a longitudinal qualitative study throughout 2020 with 41 clinical medical students at an Australian medical school. Participants completed reflective diary entries across six in-semester time-points (n = 41, 40, 39, 38, 37 and 35) and semi-structured interviews at the end of both semesters (n = 20 per semester). We analysed data using framework analysis.

RESULTS

Although participants communicated accepting health care uncertainties, described cognitive appraisals of uncertainty ranged from threatening (e.g. challenging credibility) to opportunistic (e.g. for learning and growth). Emotions in response to uncertainty were predominately described in negative terms, including worry and anxiety. Participants described a range of maladaptive and adaptive behavioural responses, including avoiding versus actively engaging with uncertainty. Despite describing typically negative emotions across time, participants' cognitive and behavioural response descriptions shifted from self-doubt and avoidance, towards acceptance of, and engagement despite uncertainty.

CONCLUSIONS

Students' descriptions of responses to uncertainty suggest existing UT conceptualisations may not holistically reflect medical students' experiences of what it means to be uncertainty 'tolerant', especially pertaining to conceptualisations of 'tolerance' centred on emotions (e.g. stress) rather than how uncertainty is ultimately managed. Extending from this study, the field could consider redefining characteristics of uncertainty 'tolerance' to focus on adaptive cognitive and behavioural responses, rather than emotional responses as key indicators of 'tolerance'.

Medical competence as a multilayered construct

BACKGROUND

The conceptualisation of medical competence is central to its use in competency-based medical education. Calls for 'fixed standards' with 'flexible pathways', recommended in recent reports, require competence to be well defined. Making competence explicit and measurable has, however, been difficult, in part due to a tension between the need for standardisation and the acknowledgment that medical professionals must also be valued as unique individuals. To address these conflicting demands, a multilayered conceptualisation of competence is proposed, with implications for the definition of standards and approaches to assessment.

THE MODEL

Three layers are elaborated. This first is a core layer of canonical knowledge and skill, 'that, which every professional should possess', independent of the context of practice. The second layer is context-dependent knowledge, skill, and attitude, visible through practice in health care. The third layer of personalised competence includes personal skills, interests, habits and convictions, integrated with one's personality. This layer, discussed with reference to Vygotsky's concept of Perezhivanie, cognitive load theory, self-determination theory and Maslow's 'self-actualisation', may be regarded as the art of medicine. We propose that fully matured professional competence requires all three layers, but that the assessment of each layer is different.

IMPLICATIONS

The assessment of canonical knowledge and skills (Layer 1) can be approached with classical psychometric conditions, that is, similar tests, circumstances and criteria for all. Context-dependent medical competence (Layer 2) must be assessed differently, because conditions of assessment across candidates cannot be standardised. Here, multiple sources of information must be merged and intersubjective expert agreement should ground decisions about progression and level of clinical autonomy of trainees. Competence as the art of medicine (Layer 3) cannot be standardised and should not be assessed with the purpose of permission to practice. The pursuit of personal excellence in this level, however, can be recognised and rewarded.

Making decisions "in the dark": Learning through uncertainty in clinical practice during Covid-19

Purpose

The purpose of this study was to explore how decision making and informal and incidental learning (IIL) emerged in the clinical learning environment (CLE) during the height of the Covid-19 pandemic. The authors' specific interest was to better understand the IIL that took place among frontline physicians who had to navigate a CLE replete with uncertainty and complexity with the future goal of creating experiences for medical students that would simulate IIL and use uncertainty as a catalyst for learning.

Method

Using a modified constructivist, grounded theory approach, we describe physicians' IIL while working during times of heightened uncertainty. Using the critical incident technique, we conducted 45-min virtual interviews with seven emergency department (ED) and five intensive care unit (ICU) physicians, who worked during the height of the pandemic. The authors transcribed and restoried each interview before applying inductive, comparative analysis to identify patterns, assertions, and organizing themes.

Results

Findings showed that the burden of decision making for physicians was influenced by the physical, emotional, relational, and situational context of the CLE. The themes that emerged for decision making and IIL were interdependent. Prominent among the patterns for decision making were ways to simplify the problem by applying prior knowledge, using pattern recognition, and cross-checking with team members. Patterns for IIL emerged through trial and error, which included thoughtful experimentation, consulting alternative sources of information, accumulating knowledge, and "poking at the periphery" of clinical practice.

Conclusions

Complexity and uncertainty are rife in clinical practice and this study made visible decision-making patterns and IIL approaches that can be built into formal curricula. Making implicit uncertainty explicit by recognizing it, naming it, and practicing navigating it may better prepare learners for the uncertainty posed by the clinical practice environment.

Uncertainty tolerance scales: Weighing up the research

Patel and Hancock explore the uncertainty tolerance literature to determine how it ties in with quantitive scales developed to measure uncertainty tolerance.

Intolerance of uncertainty and attitudes towards persons living with disabilities in medical students: Is there a correlation?

Introduction

Patients living with a disability experience an illness trajectory that may be uncertain. While navigating clinical uncertainty has been well-researched, health professionals' intolerance of uncertainty for patients living with disabilities has yet to be explored. We examined the relationship between medical students' intolerance of uncertainty with their attitudes towards people living with disabilities to better inform curricular efforts.

Methods

We employed a survey-based design consisting of the Intolerance of Uncertainty Scale (IUS) and Disability Attitudes in Healthcare (DAHC) Scale to medical students upon completion of core clerkships (end of third-year of training). Data were de-identified. Mean DAHC and IUS scores were compared with published values via t-test. Linear regression was used to examine IUS/DAHC scores for anonymized students. Pearson correlation coefficient was calculated to assess correlation between IUS and DAHC scores.

Results

Response rate was 97% (268/275 students). Mean IUS score did not differ from previously cited medical student scores, but mean DAHC score was significantly higher than previously cited scores. We observed a statistically-significant relationship between IUS and DAHC scores. Students with greater intolerance of uncertainty had lower scores for disability attitudes [F(1,243) = 8.05, value of p < 0.01], with an R ²-value of 0.032, suggesting that 3% of DAHC score variance can be explained by IUS score changes.

Conclusion

We identified a weak negative correlation between IUS and DAHC scores in medical students. Further research is needed to clarify findings and identify best practices that equip trainees with skills to care for patients with uncertain illness trajectories and patients living with disabilities.