Physicians' Reactions to Uncertainty: Refining the constructs and scales

Twelve tips for developing healthcare learners' uncertainty tolerance

BACKGROUND

Uncertainty is pervasive throughout healthcare practice. Uncertainty tolerance (i.e. adaptively responding to perceived uncertainty) is considered to benefit practitioner wellbeing, encourage person-centred care, and support judicious healthcare resource utilisation. Accordingly, uncertainty tolerance development is increasingly referenced within training frameworks. Practical approaches to support healthcare learners' uncertainty tolerance development, however, are lacking.

AIMS

Drawing on findings across the literature, and the authors' educational experiences, twelve tips for promoting healthcare learners' uncertainty tolerance were developed.

RESULTS

Tips are divided into 1. Tips for Learners, 2. Tips for Educators and Supervisors, and 3. Tips for Healthcare Education Institutions and Systems. Each tip summarises relevant research findings, alongside applications to educational practice.

CONCLUSIONS

Approaches to developing uncertainty tolerance balance factors supporting learners through uncertain experiences, with introducing challenges for learners to further develop uncertainty tolerance. These tips can reassure healthcare education stakeholders that developing learner uncertainty tolerance, alongside core knowledge, is achievable.

'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'.

Uncertainty tolerance among primary care physicians: Relationship to shared decision making-related perceptions, practices, and physician characteristics

OBJECTIVE

Understand how physicians' uncertainty tolerance (UT) in clinical care relates to their personal characteristics, perceptions and practices regarding shared decision making (SDM).

METHODS

As part of a trial of SDM training about colorectal cancer screening, primary care physicians (n = 67) completed measures of their uncertainty tolerance in medical practice (Anxiety subscale of the Physician's Reactions to Uncertainty Scale, PRUS-A), and their SDM self-efficacy (confidence in SDM skills). Patients (N = 466) completed measures of SDM (SDM Process scale) after a clinical visit. Bivariate regression analyses and multilevel regression analyses examined relationships.

RESULTS

Higher UT was associated with greater physician age (p = .01) and years in practice (p = 0.015), but not sex or race. Higher UT was associated with greater SDM self-efficacy (p < 0.001), but not patient-reported SDM.

CONCLUSION

Greater age and practice experience predict greater physician UT, suggesting that UT might be improved through training, while UT is associated with greater confidence in SDM, suggesting that improving UT might improve SDM. However, UT was unassociated with patient-reported SDM, raising the need for further studies of these relationships.

PRACTICE IMPLICATIONS

Developing and implementing training interventions aimed at increasing physician UT may be a promising way to promote SDM in clinical care.

The Impact of Health Communication Research on Medical and Health Professional Education and Training

In this essay, we review how health communication scholarship has been translated into various communication skills trainings (CSTs), we present four case studies of how health communication research informed the development and implementation of specific CSTs, and we reflect on how we can productively define "impact" in looking back as well as looking forward within this line of research.

Testing interventions to reduce clinical inertia in the treatment of hypertension: rationale and design of a pragmatic randomized controlled trial

BACKGROUND

Clinical inertia, or failure to intensify treatment when indicated, leads to suboptimal blood pressure control. Interventions to overcome inertia and increase antihypertensive prescribing have been modestly successful in part because their effectiveness varies based on characteristics of the provider, the patient, or the provider-patient interaction. Understanding for whom each intervention is most effective could help target interventions and thus increase their impact.

METHODS

This three-arm, randomized trial tests the effectiveness of 2 interventions to reduce clinical inertia in hypertension prescribing compared to usual care. Forty five primary care providers (PCPs) caring for patients with hypertension in need of treatment intensification completed baseline surveys that assessed behavioral traits and were randomized to one of three arms: 1) Pharmacist e-consult, in which a clinical pharmacist provided patient-specific recommendations for hypertension medication management to PCPs in advance of upcoming visits, 2) Social norming dashboards that displayed PCP's hypertension control rates compared to those of their peers, or 3) Usual care (no intervention). The primary outcome was the rate of intensification of hypertension treatment. We will compare this outcome between study arms and then evaluate the association between characteristics of providers, patients, their clinical interactions, and intervention responsiveness.

RESULTS

Forty-five primary care providers were enrolled and randomized: 16 providers and 173 patients in the social norming dashboards arm, 15 providers and 143 patients in the pharmacist e-consult arm, and 14 providers and 150 patients in the usual care arm. On average, the mean patient age was 64 years, 47% were female, and 73% were white. Baseline demographic and clinical characteristics of patients were similar across arms, with the exception of more Hispanic patients in the usual care arm and fewest in the pharmacist e-consult arm.

CONCLUSIONS

This study can help identify interventions to reduce inertia in hypertension care and potentially identify the characteristics of patients, providers, or patient-provider interactions to understand for whom each intervention would be most beneficial.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT, Registered: NCT04603560).

Measurement of uncertainty tolerance revisited

INTRODUCTION

Uncertainty tolerance (UT) is attracting increasing attention in medical education due to the numerous challenges associated with uncertainty in professional life. Inconsistencies in analysing the relationship between UT and moderators may arise from inadequate measurement methods. Most instruments were formulated before the most widely accepted framework was published. Our aim was to investigate the validity of an UT scale using an actual framework to corroborate with better and accurate instruments.

METHODS

A total of 1052 students were invited. Various psychometric methods were used to explore validity of the TAMSAD scale in light of actual framework. Classic exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed. Secondly, content item classification was triangulated with exploratory graph analysis (EGA), and the new EFA, CFA, and cognitive diagnostic modelling (CDM) analysis were conducted. The reliability was calculated using Cronbach's alpha and McDonald's omega.

RESULTS

A total of 694 students (65.9%) responded to the questionnaire. The reliability of the TAMSAD scale was 0.782. The initial EFA revealed no clear interpretable dimensions. The TAMSAD scale items can be classified into sources of uncertainty. The EGA has three dimensions, and the new EFA led to a 17-item TAMSAD scale with the following three dimensions: ambiguity, complexity, and probability. These dimensions lead to better adjustment fit indices in the new CFA and CDM analyses.

CONCLUSION

We found evidence that the TAMSAD scale can be considered a multidimensional scale, organised in terms of sources of uncertainty.

Factors that affect GP referral of a child with intellectual disability for a mild illness: A discrete choice experiment

BACKGROUND

General practitioners (GP) report multiple challenges when treating individuals with intellectual disabilities which may influence referral rates. The study aimed to establish factors that influence GP's decision-making when referring a child with intellectual disabilities to the emergency department.

METHOD

Discrete choice experiments (DCEs) are increasingly used in health research to further understand complex decision making. A DCE was designed to assess the relative importance of factors that may influence a GP's (N = 157) decision to refer.

RESULTS

A random parameters model indicated that perceived limited parental capacity to manage an illness was the most important factor in the decision to refer a child to the ED, followed by a repeat visit, a referral request from the parent, and a Friday afternoon appointment.

CONCLUSION

Understanding the factors that influence referral is important for service improvement and to strengthen primary care provision for this population and their families.

Impact of COVID-19 Policies on Hospitalists' Psychological Safety

OBJECTIVES

The coronavirus disease 2019 pandemic brought about many changes in work environment and interpersonal interactions to prevent the spread of infection. Policies such as ubiquitous masking, virtual meetings, physician distancing, and decreased communal eating changed the inpatient work environment. This study aims to look at the impact of these changes on hospitalists' psychological safety.

METHODS

We surveyed hospitalists on how these changes affected their well-being and feelings of psychological safety.

RESULTS

Masking, virtual meetings, and fewer opportunities to eat together decreased connection with colleagues. Virtual meetings and social distancing decreased some aspects of psychological safety.

CONCLUSIONS

This study highlights the importance of finding ways to foster connection and decrease burnout while continuing to prevent the spread of infection.

Identifying validity evidence for uncertainty tolerance scales: A systematic review

PURPOSE

Uncertainty tolerance (UT) is increasingly valued as a medical graduate attribute and broadly measured among medical student populations. However, the validity evidence underpinning UT scale implementation has not been summarised across studies. The present work evaluates UT scale validity evidence to better inform when, why and how UT scales ought to be used and to identify remaining validity evidence gaps.

METHODS

A literature search for psychometric studies of UT scales was completed in 2022. Records were included if they implemented one of the four most cited UT scales (i.e. Physicians' Reactions to Uncertainty scale 1990 [PRU1990] or 1995 [PRU1995], Tolerance for Ambiguity [TFA] scale or Tolerance of Ambiguity in Medical Students and Doctors scale [TAMSAD]) in a population of physicians and/or medial students and presented validity evidence according to the Standards for Educational and Psychological Testing framework. Included studies were rated and analysed according to evidence for test content, response processes, internal structure, relations to other variables and consequences of testing.

RESULTS

Among the investigated scales, 'relations to other variables' and 'internal structure' were the most commonly reported forms of validity evidence. No evidence of 'response processes' or 'consequences of testing' was identified. Overall, the PRU1990 and PRU1995 demonstrated the strongest validity evidence, although evidence primarily related to physician populations.

CONCLUSIONS

None of the studied scales demonstrated evidence for all five sources of validity. Future research would benefit from assessing validity evidence for 'response processes' and 'consequences of testing' among physicians and medical students at different training/career stages to better understand UT construct conceptualisation in these populations. Until further and stronger validity evidence for UT scales is established, we caution against implementing UT scales outside of research settings (e.g. for higher stakes decision making).

Communication about diagnosis, prognosis, and prevention in the memory clinic: perspectives of European memory clinic professionals

BACKGROUND

The paradigm shift towards earlier Alzheimer's disease (AD) stages and personalized medicine creates new challenges for clinician-patient communication. We conducted a survey among European memory clinic professionals to identify opinions on communication about (etiological) diagnosis, prognosis, and prevention, and inventory needs for augmenting communication skills.

METHODS

Memory clinic professionals (N = 160) from 21 European countries completed our online survey (59% female, 14 ± 10 years' experience, 73% working in an academic hospital). We inventoried (1) opinions on communication about (etiological) diagnosis, prognosis, and prevention using 11 statements; (2) current communication practices in response to five hypothetical cases (AD dementia, mild cognitive impairment (MCI), subjective cognitive decline (SCD), with ( +) or without ( -) abnormal AD biomarkers); and (3) needs for communication support regarding ten listed communication skills.

RESULTS

The majority of professionals agreed that communication on diagnosis, prognosis, and prevention should be personalized to the individual patient. In response to the hypothetical patient cases, disease stage influenced the inclination to communicate an etiological AD diagnosis: 97% would explicitly mention the presence of AD to the patient with AD dementia, 68% would do so in MCI + , and 29% in SCD + . Furthermore, 58% would explicitly rule out AD in case of MCI - when talking to patients, and 69% in case of SCD - . Almost all professionals (79-99%) indicated discussing prognosis and prevention with all patients, of which a substantial part (48-86%) would personalize their communication to patients' diagnostic test results (39-68%) or patients' anamnestic information (33-82%). The majority of clinicians (79%) would like to use online tools, training, or both to support them in communicating with patients. Topics for which professionals desired support most were: stimulating patients' understanding of information, and communicating uncertainty, dementia risk, remotely/online, and with patients not (fluently) speaking the language of the country of residence.

CONCLUSIONS

In a survey of European memory clinic professionals, we found a strong positive attitude towards communication with patients about (etiological) diagnosis, prognosis, and prevention, and personalization of communication to characteristics and needs of individual patients. In addition, professionals expressed a need for supporting tools and skills training to further improve their communication with patients.

Finding Themselves, Their Place, Their Way: Uncertainties Identified by Medical Students

Phenomenon: Navigating uncertainty is a core skill when practicing medicine. Increasingly, the need to better prepare medical students for uncertainty has been recognized. Our current understanding of medical students' perspectives on uncertainty is primarily based on quantitative studies with limited qualitative research having been performed to date. We need to know from where and how sources of uncertainty can arise so that educators can better support medical students learning to respond to uncertainty. This research's aim was to describe the sources of uncertainty that medical students identify in their education. Approach: Informed by our previously published framework of clinical uncertainty, we designed and distributed a survey to second, fourth-, and sixth-year medical students at the University of Otago, Aotearoa New Zealand. Between February and May 2019, 716 medical students were invited to identify sources of uncertainty encountered in their education to date. We used reflexive thematic analysis to analyze responses. Findings: Four-hundred-sixty-five participants completed the survey (65% response rate). We identified three major sources of uncertainty: insecurities, role confusion, and navigating learning environments. Insecurities related to students' doubts about knowledge and capabilities, which were magnified by comparing themselves to peers. Role confusion impacted upon students' ability to learn, meet the expectations of others, and contribute to patient care. Navigating the educational, social, and cultural features of clinical and non-clinical learning environments resulted in uncertainty as students faced new environments, hierarchies, and identified challenges with speaking up. Insights: This study provides an in-depth understanding of the wide range of sources of medical students' uncertainties, encompassing how they see themselves, their roles, and their interactions with their learning environments. These results enhance our theoretical understanding of the complexity of uncertainty in medical education. Insights from this research can be applied by educators to better support students develop the skills to respond to a core element of medical practice.

Pediatricians' Communication about Medical Uncertainty: Goal-Oriented Communication and Uncertainty Management

Despite the prevalence of uncertainty in medicine, many physicians experience anxiety as a result of medical uncertainty and are reluctant to discuss uncertainty with others. When pediatricians do disclose uncertainty to parents, they are managing both the parents' and their own feelings of uncertainty. The current study applies uncertainty management theory and multiple goals theory to explore pediatricians' communication about uncertainty. We collected data using in-depth semi-structured interviews with 18 pediatricians. The results suggest that pediatricians prioritize task and relational goals with parents and task and identity goals with fellow physicians. Though, their appraisal of uncertainty influences their goal-oriented communication. The results highlight the relationship between uncertainty management theory and a multiple goals framework. These frameworks provide a valuable approach for gaining a more thorough understanding of pediatrician communication in the context of uncertainty.

"I Want Them to Still Trust Me with Their Child's Care": A Longitudinal Study of Pediatric Residents' Reactions to and Communication with Parents about Medical Uncertainty across Residency

Physicians in residency training experience high levels of medical uncertainty, yet they are often hesitant to discuss uncertainty with parents. Guided by the theory of motivated information management and a multiple goals perspective, this mixed-methods longitudinal study examines associations among residents' tolerance of and reactions to uncertainty, efficacy communicating about uncertainty, and perceptions of parents' trust in them as physicians. To contextualize these associations, we also examined residents' task, identity, and relational goals when communicating about uncertainty with parents. We surveyed 47 pediatric residents at the beginning of each year of their residency program. As they progressed through their training, residents' uncertainty-related anxiety and reluctance to communicate uncertainty to parents decreased, and their efficacy communicating uncertainty with parents increased. Residents' concerns about bad outcomes remained unchanged. Residents pursued multiple, often conflicting, conversational goals when communicating uncertainty with parents. Results reveal important considerations for addressing how residents can manage their uncertainty in productive ways.

The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department: A Discrete Choice Experiment

A General Practitioner's (GP) decision to refer a patient to the emergency department (ED) requires consideration of a multitude of factors, and significant variation in GP referral patterns to secondary care has been recorded. This study examines the contextual factors that influence GPs when referring a paediatric patient with potentially self-limiting clinical symptoms to the ED. Utilizing a discrete choice experiment, survey data was collected from GPs in Ireland (n = 142) to elicit factors influencing this decision across five attributes: time/day of visit, repeat presentation, parents' capacity to cope, parent requesting a referral, and access to a paediatric outpatient clinic/day unit. Using mixed logit models, all attributes were statistically significant, with repeat presentation and parents lacking the capacity to cope identified as the strongest contextual factors leading to the decision to refer to the ED. There has been limited exploration of this decision-making process and this study uses a robust design to identify and rank contextual attributes. Enhanced awareness of contextual factors on referral decision-making is crucial to understanding patterns of paediatric unscheduled healthcare and to planning services that respond to parent's and children's needs, whilst allowing GPs to make decisions in the best interest of the child.

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

IMPORTANCE

Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.

OBJECTIVES

To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.

EXPOSURES

Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.

RESULTS

We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

Decision making under uncertainty in the diagnosis and management of Alzheimer's Disease in primary care: A study protocol applying concepts from neuroeconomics

Background

The current management of patients with Dementia, primarily with Alzheimer's Disease (AD) is rapidly evolving. However, limited information is available about the current gaps and decision-making in primary care.

Objectives

To evaluate factors associated with gaps, risk preferences regarding diagnostic and therapeutic choices in the management of patients with AD by primary care physicians (PCP) from across Canada.

Methods

We propose a non-interventional, cross-sectional pilot study involving 120 primary care physicians referred from the College of Family Physicians of Canada to assess diagnostic and therapeutic decisions in the management of ten simulated AD-related case-scenarios commonly encountered in clinical practice. We initially describe the current landscape and gaps regarding diagnostic and therapeutic challenges in the management of patients with AD in primary care. Then, we provide concepts from behavioral economics and neuroeconomics applied to medical decision-making. Specifically, we include standardized tests to measure risk aversion, physicians' reactions to uncertainty, and questions related to risk preferences in different domains. Finally, we summarize the protocol to be implemented to address our goals. The primary study outcome is the proportion of participants that elect to defer initial investigations to the specialist and the associated factors. Secondary outcomes include the proportion of PCP willing to order cerebral spinal fluid studies, PET scans, or initiate treatment according to the simulated case-scenarios. The study will be conducted in English and French.

Conclusions

The study findings will contribute a better understanding of relevant factors associated with diagnostic and therapeutic decisions of PCP in the management of AD, identifying participant's preferences and evaluating the role of behavioral aspects such tolerance to uncertainty, aversion to ambiguity, and therapeutic inertia.

The impact of clinical uncertainty in the graduate medical education (GME) learning environment: A mixed-methods study

BACKGROUND

Uncertainty is ubiquitous in medicine. Studies link intolerance of uncertainty to burnout, ineffective communication, cognitive bias, and inappropriate resource use. Little is known about how uncertainty manifests in the clinical learning environment. We aimed to explore the perceptions and experiences of uncertainty among residents and attendings.

METHODS

We conducted a mixed-methods study including a survey, semi-structured interviews, and ethnographic observations during rounds with residents and attendings at an academic medical center. The survey included three validated instruments: Physicians' Reaction to Uncertainty Scale; Maslach Burnout Inventory 2-item; and Educational Climate Inventory.

RESULTS

35/60 (58%) of eligible residents and 14/21 (67%) attendings completed the survey. Residents reported higher anxiety due to uncertainty than attendings, higher concern about bad outcomes, and greater reluctance to disclose uncertainty to patients. Residents reported increased symptoms of burnout (p < .05). Perceiving the learning environment as more competitive correlated with reluctance to disclose uncertainty (r = -0.44; p < .01). Qualitative themes included: recognizing and facing uncertainty, and consequences for the learning environment. Observations revealed senior clinicians have greater comfort acknowledging uncertainty.

CONCLUSIONS

Medical curricula should be developed to promote recognition and acknowledgement of uncertainty. Greater acknowledgement of uncertainty, specifically by attendings and senior residents, may positively impact the clinical learning environment.

Reliability of Uncertainty Tolerance Scales Implemented Among Physicians and Medical Students: A Systematic Review and Meta-Analysis

PURPOSE

Uncertainty tolerance (UT) is a construct describing individuals' perceptions of, and responses to, uncertainty across their cognition, emotion, and behavior. Various UT scales have been designed for physician and medical student populations. However, links between UT and other variables (e.g., training stages) are inconsistent, raising concerns about scale reliability and validity. As reliability is a precondition for validity, a necessary first step in assessing UT scales' efficacy is evaluating their reliability. Accordingly, the authors conducted a meta-analysis of the reliability of UT scales designed for, and implemented among, physician and medical student populations.

METHOD

In 2020, the authors searched 4 electronic databases alongside a citation search of previously identified UT scales. They included English-language, peer-reviewed studies that implemented UT scales in physician and/or medical student populations and reported reliability evidence. A meta-analysis of studies' Cronbach's alphas evaluated aggregated internal consistency across studies; subgroup analyses evaluated UT scales by named scale, population, and item characteristics.

RESULTS

Among 4,124 records screened, 35 studies met the inclusion criteria, reporting 75 Cronbach's alphas. Four UT scales appeared in at least 3 included studies: Physicians' Reactions to Uncertainty scale 1990 (PRU1990) and 1995 (PRU1995) versions, Tolerance for Ambiguity scale (TFA), and Tolerance of Ambiguity in Medical Students and Doctors scale (TAMSAD). The scores from these scales ranged in reliability from very good (PRU1990: 0.832, PRU1995: 0.818) to respectable (TFA: 0.761, TAMSAD: 0.711). Aggregated internal consistency was significantly higher ( P < .001) among physicians (0.797) than medical students (0.711).

CONCLUSIONS

UT scales generally demonstrated respectable internal consistency when administered among physicians and medical students, yet the reliability among medical students was significantly lower. The authors caution against using UT scores for decision-making purposes (e.g., applicant selection, program evaluation), especially among medical student populations. Future research should explore the reasons underlying these observed population differences.

'A whole lot of uncertainty': A qualitative study exploring clinical medical students' experiences of uncertainty stimuli

INTRODUCTION

Uncertainty tolerance (UT) describes how individuals respond to stimuli of uncertainty, with low UT among medical doctors and students linked to negative outcomes such as burnout. UT research in medical education has focused on measuring the construct, with little research seeking to understand how medical students experience uncertainty. Hence, knowledge on how education may shape students' UT development is lacking. As a first step to understanding students' UT, we asked 'How do medical students, in their clinical years, experience uncertainty stimuli?'

METHODS

Utilising a social constructionist approach, we undertook a qualitative study with 41 clinical years medical students. Data were collected during the 2020 academic year employing in-semester reflective diary entries (n = 230 entries), and semi-structured interviews at the end of semesters (n = 40 interviews). Data were analysed by framework analysis.

RESULTS

Students described three major themes of uncertainty stimuli: (i) educational uncertainty, (ii) professional uncertainty and (iii) clinical uncertainty. Educational uncertainty was the dominant stimulus described by students and represents unknowns related to what students needed to learn and how to learn within the context of clinical placements. Professional uncertainty encompassed questions about who students are as developing professionals and who they would be as doctors. Clinical uncertainty was the least represented stimulus and concerned aspects of patient care where the body of medical knowledge is unable to provide clear answers.

CONCLUSIONS

Our findings indicate that clinical learners experience wide reaching uncertainties and suggest that students' stimuli may differ from those of clinicians with more established knowledge and careers. This work now paves the way forward in developing educational interventions to foster UT, such as modifying uncertainties not integral to learning, and purposefully introducing clinical uncertainties relevant to students' learning stage.

Therapeutic Decision-Making Under Uncertainty in the Management of Spinal Muscular Atrophy: Results From DECISIONS-SMA Study

Introduction

There are many uncertainties about treatment selection and expectations regarding therapeutic goals and benefits in the new landscape of spinal muscular atrophy (SMA). Our aim was to assess treatment preferences and expectations of pediatric neurologists caring for patients with SMA.

Methods

DECISIONS-SMA is a non-interventional, cross-sectional pilot study that assessed pediatric neurologists with expertise in SMA from across Spain. Participants were presented with 11 simulated case scenarios of common encounters of patients with SMA type 1 and 2 to assess treatment initiation, escalation, or switches. We also asked for the expected benefit with new therapies for four simulated case scenarios. Participants completed a behavioral battery to address their tolerance to uncertainty and aversion to ambiguity. The primary outcome was therapeutic inertia (TI), defined as the number of simulated scenarios with lack of treatment initiation or escalation when warranted over the total (11) presented cases.

Results

A total of 35 participants completed the study. Participants’ mean (SD) expectation for achieving an improvement by starting a new therapy for SMA type 1 (case 1, a 5-month-old) and SMA type 2 (case 6, a 1-year-old) were both 59.6% (± 21.8), but declined to 20.2% (± 12.2) for a case scenario of a 16-year-old treatment-naïve patient with long-standing SMA type 2 with severe disability. The mean (SD) TI score was 4.2 (1.7), and 3.29 (1.5) for treatment initiation. Of a total 385 individual responses, TI was observed in 147 (38.2%) of treatment choices. The multivariable analysis showed that lower aversion to ambiguity (p = 0.019) and lower expectation of treatment response (p = 0.007) were associated with higher TI after adjustment for participants’ age and years of experience. Older age (p = 0.019), lower years of experience (p = 0.035), lower aversion to ambiguity (p = 0.015), and lower expectation of treatment benefits (p = 0.006) were associated with inertia for treatment initiation.

Conclusions

Pediatric neurologists managing patients with SMA were optimistic regarding treatment improvement in cases with early diagnosis, but had lower expectations when treatment delays and advanced patient age were present. Low aversion to ambiguity, low expectation of treatment benefits, and lower clinical experience were more likely to make suboptimal decisions, resulting in lack of treatment initiation, escalation, and TI.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-022-00366-4.

Therapeutic decisions under uncertainty for spinal muscular atrophy: The DECISIONS-SMA study protocol

Background

The therapeutic landscape for spinal muscular atrophy has changed in the last few years, encompassing respiratory/motor function and life expectancy benefits. However, physicians still have the challenge of tailoring individuals’ treatment to therapeutic goals, disease progression, patient/caregiver’s preferences, and personal experience to achieve an optimal risk/benefit balance. This study aims to provide insight into the preferred treatment choices of pediatric neurologists managing spinal muscular atrophy in their daily practice and to recognize behavioral factors that may influence decision-making.

Methods

This is a noninterventional, cross-sectional pilot study involving 50 pediatric neurologists managing spinal muscular atrophy in Spain. We designed an online platform that contains 13 simulated case scenarios of common presentations of patients with spinal muscular atrophy. The primary study outcome will be treatment preferences according to the percentages of participants who select treatment initiation when recommended, switch therapies when there is evidence of disease progression, and select treatment discontinuation when disease progression puts patients outside treatment recommendation (11 case scenarios). Secondary outcomes include therapeutic inertia prevalence (11 case scenarios), herding phenomenon prevalence (2 case scenarios), care-related regret prevalence (specific questions) and intensity (10-item Regret Intensity Scale), occupational burnout prevalence (nonproprietary single-item measure), and risk preferences (uncertainty test and risk aversion assessment).

Conclusions

The study findings will contribute to better understand relevant factors associated with therapeutic decisions of pediatric neurologists in spinal muscular atrophy, identifying treatment preferences and evaluating the role of behavioral aspects such as therapeutic inertia, herding, regret, and workplace burnout.

An Interprofessional Group Intervention to Promote Faculty Well-Being: A Randomized Clinical Trial

INTRODUCTION

To evaluate the effect on engagement, relational connection, and burnout of an intervention involving clinical faculty meeting in interprofessional self-facilitated groups and to determine whether a written discussion guide is necessary to achieve benefit.

METHODS

This is a randomized controlled trial, conducted at a large US academic medical center from May to August 2018. Subjects included 25 clinical physicians, nurse practitioners, and certified nurse midwives. The intervention involved three monthly self-facilitated groups for faculty. Groups were randomized to have no discussion guide, or to receive a one-page guide. Outcomes of burnout, engagement, and empowerment in work, and stress from uncertainty were assessed using validated metrics.

RESULTS

Rates of emotional exhaustion and depersonalization decreased significantly over the course of the 3-month study (56%-36%; P < .001; and 20%-15%; P = .006) and overall burnout decreased from 56% to 41% of faculty (P = .002). The percentage of faculty who felt engaged in their work increased from 80% to 96% (P = .03). No statistically significant differences in empowerment at work or in reaction to uncertainty were seen. The groups without a discussion guide had equivalent outcomes and benefits. Cost per participant was under $100.

DISCUSSION

A three-month, low-cost, self-facilitated series of dinner meetings for interprofessional clinical faculty decreased burnout and improved engagement, sense of connection to colleagues, and sense of departmental commitment to well-being. Structured discussion guides were not necessary to achieve benefit. This study broadens the possibilities for cost-effective opportunities to transform institutional culture and effectively enhance faculty well-being.

Trainee Uncertainty around Intervening When Patients Decompensate

Background

Trainees in acute care specialties often grapple with the decision to perform an invasive procedure in a rapidly decompensating patient, for whom the benefits and risks are inherently uncertain. The difference between trainees who know when to act and when to seek supervision and those who do not is often linked to individual trainee psychological and cultural perceptions of uncertainty. But how much comfort with uncertainty relates to the situational context rather than the trainee traits is underexplored.

Objective

The objective of this study was to explore trainee actions around decompensating patients and assess the degree to which invasive intervention and supervision seeking depend on situational certainty or individual trait-based perceptions of uncertainty.

Methods

A total of 41 internal medicine residents completed a survey to measure anxiety related to uncertainty using the Physicians’ Reactions to Uncertainty (PRU) tool and to measure uncertainty avoidance using the Values Survey Module (VSM) before responding to 14 written emergency situations. Half of the scenarios contain sufficient diagnostic certainty to warrant aggressive intervention, and half lack sufficient diagnostic clarity to offset the risk of intervention. Mixed multivariable modeling was used to identify the relationship between planned invasive intervention, situational uncertainty, and trait-based perceptions of uncertainty measured in the PRU and VSM.

Results

Trainees’ first actions were appropriate in 60% of cases. Multivariable modeling suggested that situational certainty was more predictive of upfront intervention (odds ratio [OR], 30.5; P < 0.0001) than trait-based PRU (OR, 1.22; P = 0.05) and VSM (OR, 1.73; P < 0.0001). Similarly, situational certainty was more predictive of reduced supervision seeking (OR, 0.20; P < 0.0001) than trait-based PRU (OR, 2.03; P < 0.001) and VSM (P = not significant).

Conclusions

Situation-specific certainty was more strongly correlated with invasive intervention in cases of decompensated patients than individual trainee traits. Focusing on trainee contextual understanding of procedural risk–benefit ratios in decompensating patients holds more promise for improving trainee actions and supervision seeking than tackling their perceptions around uncertainty.

Tolerance for Uncertainty and Professional Development: a Normative Analysis

Scholars from a range of disciplines including medicine, sociology, psychology, and philosophy have addressed the concepts of ambiguity and uncertainty in medical practice and training. Most of this scholarship has been descriptive, focusing on defining and measuring ambiguity and uncertainty tolerance or tracking clinicians' responses to ambiguous and uncertain situations. Meanwhile, scholars have neglected some fundamental normative questions: Is tolerance of uncertainty good; if so, to what extent? Using a philosophical approach to these questions, we show that neither tolerance nor intolerance of uncertainty is necessarily a good or bad trait. Rather, both tolerance and intolerance of uncertainty can give physicians advantages while at the same time exposing them to pitfalls in clinical practice. After making this case, we argue that cultivating certain virtues-like courage, diligence, and curiosity-could help clinicians avoid the dangers of excessive tolerance and intolerance of uncertainty. Finally, we suggest that medical educators develop curricula and career counseling beginning with matriculation and proceeding through specialty choice and residency training that explicitly address trainees' responses to clinical uncertainty. These programs should encourage trainees, students and residents, to be mindful of their reactions to uncertainty and help them develop virtues that will allow them to avoid the hazards of extreme tolerance or intolerance of uncertainty.

Six hours to study: temporality and ignorance in medical education

Individual scientists, clinicians, and other experts cannot have absolute knowledge of all of the theories, methods, models, and findings in their field of practice. Rather, these individuals make choices about the kind of information that will be most meaningful and impactful in their work, while choosing - or being compelled to choose - what knowledge to overlook or ignore: a process identified as sufficient knowledge. In biomedicine, medical students are socialized to deliberately decide what information matters most; so, too, do practicing physicians openly acknowledge that they make choices around knowledge in daily practice. Within this process, time is a critical factor that mediates epistemological decision-making. In other words, how does time bound or restrict what forms and depth of medical knowledge that physicians and future physicians prioritize? When would someone intentionally limit time in order to constrain the amount and types of information he, she, or they acquire? To answer these questions, this study draws upon interviews and participant observation conducted with students at a medical school in the American Midwest. This article seeks to answer the aforementioned questions and to provide a new framework for, and expand discussions of, agnotology in the anthropology of medicine.

Skeptical self-regulation: Resident experiences of uncertainty about uncertainty

OBJECTIVES

Managing uncertainty is central to expert practice, yet how novice trainees navigate these moments is likely different than what has been described by experienced clinicians. Exploring trainees' experiences with uncertainty could therefore help explicate the unique cues that they attend to, how they appraise their comfort in these moments and how they enact responses within the affordances of their training environment.

METHODS

Informed by constructivist grounded theory, we explored how novice emergency medicine trainees experienced and managed clinical uncertainty in practice. We used a critical incident technique to prompt participants to reflect on experiences with uncertainty immediately following a clinical shift, exploring the cues they attended to and the approaches they used to navigate these moments. Two investigators coded line-by-line using constant comparison, organising the data into focused codes. The research team discussed the relationships between these codes and developed a set of themes that supported our efforts to theorise about the phenomenon.

RESULTS

We enrolled 13 trainees in their first two years of postgraduate training across two institutions. They expressed uncertainty about the root causes of the patient problems they were facing and the potential management steps to take, but also expressed a pervasive sense of uncertainty about their own abilities and their appraisals of the situation. This, in turn, led to challenges with selecting, interpreting and using the cues in their environment effectively. Participants invoked several approaches to combat this sense of uncertainty about themselves, rehearsing steps before a clinical encounter, checking their interpretations with others and implicitly calibrating their appraisals to those of more experienced team members.

CONCLUSIONS

Trainees' struggles with the legitimacy of their interpretations impact their experiences with uncertainty. Recognising these ongoing struggles may enable supervisors and other team members to provide more effective scaffolding, validation and calibration of clinical judgments and patient management.

Prevalence and Tolerance of Prognostic Uncertainty Among Thoracic Oncologists

We undertook a cross-sectional survey of a random sample of thoracic oncologists from the American Society of Clinical Oncology clinical directory to characterize whether prognostic uncertainty has increased and if tolerance of uncertainty is associated with prognostic discussion practices. We also assessed the Physicians' Reactions to Uncertainty Scale and presented a vignette about an incurable patient with uncertain life expectancy. One hundred and ninety-two of 438 surveys (43.8%) were received. Of the respondents, 52.1% agreed "there is more prognostic uncertainty in the management of lung cancer now than 10 years ago," and 37.4% noted difficulty "staying up-to-date." In multivariable analyses, physician-reported anxiety about uncertainty (p = .05) and reluctance to disclose uncertainty (p = .04) were inversely associated with reporting having prognostic discussions with most patients. For the vignette, 92.1% reported they would discuss incurability, but only 76.3% said they would discuss the patient's life expectancy. Our data suggest prognostic uncertainty has increased in thoracic oncology and oncologists' tolerance of uncertainty may affect discussion practices.

Opiophobia in Emergency Department Healthcare Providers: A Survey in Western Switzerland

Opiophobia contributes to oligoanalgesia in the emergency department (ED), but its definition varies, and its association to healthcare providers’ personality traits has been scantly explored. Our purpose was to study the different definitions of opiophobia and their association with two personality traits of doctors and nurses working in EDs, namely the stress from uncertainty and risk-taking. We used three online questionnaires: the ‘Attitude Towards Morphine Use’ Score (ATMS), the Stress From Uncertainty Scale (SUS) and the Risk-Taking Scale (RTS). Doctors and nurses from nine hospital EDs in francophone Switzerland were invited to participate. The ATMS score was analyzed according to demographic characteristics, SUS, and RTS. The response rate was 56%, with 57% of respondents being nurses and 63% women. Doctors, less experienced and non-indigenous participants had a significantly higher ATMS (all p ≤ 0.01). The main contributors of the ATMS were the fear of side effects and of addiction. In multivariate analysis, being a doctor, less experience and non-indigenous status were predictive of the ATMS; each point of the SUS increased the ATMS by 0.24 point. The fear of side effects and of addiction were the major contributors of opiophobia among ED healthcare providers; opiophobia was also associated with their personality traits.

Educational Intervention Reduced Family Medicine Residents' Intention to Request Diagnostic Tests: Results of a Controlled Trial

OBJECTIVE

Dealing with uncertainty is a core competence for physicians. To evaluate the impact of an educational intervention on family medicine residents' (FMRs') intention to request diagnostic tests and their attitudes toward uncertainty.

METHODS

Nonrandomized controlled trial. Intervention group (IG) FMRs participated in interactive "dealing with uncertainty" seminars comprising statistical lessons and diagnostic reasoning. Control group (CG) FMRs participated in seminars without in-depth diagnostic lessons. FMRs completed the Dealing with Uncertainty Questionnaire (DUQ), comprising the Diagnostic Action and Diagnostic Reasoning scales. The Physicians' Reaction to Uncertainty (PRU) questionnaire, comprising 4 scales (Anxiety Due to Uncertainty, Concern about Bad Outcomes, Reluctance to Disclose Uncertainty to Patients, and Reluctance to Disclose Mistakes to Physicians) was also completed. Follow-up was performed 3 months later. Differences were calculated with repeated-measures analysis of variance.

RESULTS

In total, 107 FMRs of the IG and 102 FMRs of the CG participated at baseline and follow-up. The mean (SD) Diagnostic Action scale score decreased from 24.0 (4.8) to 22.9 (5.1) in the IG and increased in the CG from 23.7 (5.4) to 24.1 (5.4), showing significant group difference (P = 0.006). The Diagnostic Reasoning scale increased significantly (P = 0.025) without a significant group difference (P = 0.616), from 19.2 (2.6) to 19.7 (2.4) in the IG and from 18.1 (3.3) to 18.8 (3.2) in the CG. The PRU scale Anxiety Due to Uncertainty decreased significantly (P = 0.029) without a significant group difference (P = 0.116), from 20.5 (4.8) to 18.5 (5.5) in the IG and from 19.9 (5.5) to 19.0 (6.0) in the CG.

CONCLUSION

The structured seminar reduced self-rated diagnostic test requisition. The change in Anxiety Due to Uncertainty and Diagnostic Reasoning might be due to an unspecific accompanying effect of the extra-occupational seminars for residents.

Warning bells: How clinicians leverage their discomfort to manage moments of uncertainty

OBJECTIVES

It remains unclear how medical educators can more effectively bridge the gap between trainees' intolerance of uncertainty and the tolerance that experienced physicians demonstrate in practice. Exploring how experienced clinicians experience, appraise and respond to discomfort arising from uncertainty could provide new insights regarding the kinds of behaviours we are trying to help trainees achieve.

METHODS

We used a constructivist grounded theory approach to explore how emergency medicine faculty experienced, managed and responded to discomfort in settings of uncertainty. Using a critical incident technique, we asked participants to describe case-based experiences of uncertainty immediately following a clinical shift. We used probing questions to explore cognitive, emotional and somatic manifestations of discomfort, how participants had appraised and responded to these cues, and how they had used available resources to act in these moments of uncertainty. Two investigators coded the data line by line using constant comparative analysis and organised transcripts into focused codes. The entire research team discussed relationships between codes and categories, and developed a conceptual framework that reflected the possible relationships between themes.

RESULTS

Participants identified varying levels of discomfort in their case descriptions. They described multiple cues alerting them to problems that were evolving in unexpected ways or problems with aspects of management that were beyond their abilities. Discomfort served as a trigger for participants to monitor a situation with greater attention and to proceed more intentionally. It also served as a prompt for participants to think deliberately about the types of human and material resources they might call upon strategically to manage these uncertain situations.

CONCLUSIONS

Discomfort served as a dynamic means to manage and respond to uncertainty. To be 'tolerant' of uncertainty thus requires clinicians to embrace discomfort as a powerful tool with which to grapple with the complex problems pervasive in clinical practice.

Factors associated with physicians' recommendations for managing low-risk papillary thyroid cancer

BACKGROUND

The 2015 American Thyroid Association endorsed less aggressive management for low-risk papillary thyroid cancer (LR-PTC). We aimed to identify factors influencing physicians' recommendations for LR-PTC.

METHODS

We surveyed members of three professional societies and assessed respondents' recommendations for managing LR-PTC using patient scenarios. Multivariable logistic regression models identified clinical and non-clinical factors associated with recommending total thyroidectomy (TT) and active surveillance (AS).

RESULTS

The 345 respondents included 246 surgeons and 99 endocrinologists. Physicians' preference for their own management if diagnosed with LR-PTC had the strongest association with their recommendation for TT and AS (TT: OR 12.3; AS: OR 7.5, p < 0.001). Physician specialty and stated patient preference were also significantly associated with their recommendations for both management options. Respondents who received information about AS had increased odds of recommending AS.

CONCLUSIONS

Physicians' recommendations for LR-PTC are strongly influenced by non-clinical factors, such as personal treatment preference and specialty.

"I Was Worried About the Patient, but I Wasn't Feeling Worried": How Physicians Judge Their Comfort in Settings of Uncertainty

PURPOSE

Clinical educators often raise concerns that learners are not comfortable with uncertainty in clinical work, yet existing literature provides little insight into practicing clinicians' experiences of comfort when navigating the complex, ill-defined problems pervasive in practice. Exploring clinicians' comfort as they identify and manage uncertainty in practice could help us better support learners through their discomfort.

METHOD

Between December 2018 and April 2019, the authors employed a constructivist grounded theory approach to explore experiences of uncertainty in emergency medicine faculty. The authors used a critical incident technique to elicit narratives about decision making immediately following participants' clinical shifts, exploring how they experienced uncertainty and made real-time judgments regarding their comfort to manage a given problem. Two investigators analyzed the transcripts, coding data line-by-line using constant comparative analysis to organize narratives into focused codes. These codes informed the development of conceptual categories that formed a framework for understanding comfort with uncertainty.

RESULTS

Participants identified multiple forms of uncertainty, organized around their understanding of the problems they were facing and the potential actions they could take. When discussing their comfort in these situations, they described a fluid, actively negotiated state. This state was informed by their efforts to project forward and imagine how a problem might evolve, with boundary conditions signaling the borders of their expertise. It was also informed by ongoing monitoring activities pertaining to patients, their own metacognitions, and their environment.

CONCLUSIONS

The authors' findings offer nuances to current notions of comfort with uncertainty. Uncertainty involved clinical, environmental, and social aspects, and comfort dynamically evolved through iterative cycles of forward planning and monitoring.

Tools to manage medical uncertainty

BACKGROUND AND AIMS

Despite an explosion of evidence-based guidelines, many decisions in clinical practice remain shrouded in uncertainty. Physicians could view ambiguous situations as a source of threat. Uncertainty results from personal lack of knowledge, limits of current medical knowledge and the inability to distinguish between the two. The purpose of this review is to study the prevalence, effects and management of medical uncertainty in clinical practice.

METHODS

PubMed search for articles on prevalence and management of medical uncertainty.

RESULTS AND CONCLUSION

Intolerance to uncertainty among physicians may result in increased test-ordering tendencies, failure to comply with evidence-based guidelines, guide career choices, and result in decreased comfort with geriatric, chronic illness and psychological problems. Factors causing variability of disease management includes: patient factors(inappropriate prioritization, risk aversion, expectations), physicians factors(lack of knowledge, intolerance to medical uncertainty, limited resources, time constraints), biological variability of patient, health system factors, patients comorbidities, technological and media influences contributing further to unrealistic expectations. Physicians' perceptions of uncertainty in their daily work vary considerably. Urologist and orthopedic surgeons reported less uncertainty in their daily routine compared to psychiatrists, family practitioners and general internists. Effective methods of managing uncertainty include, consensus building among physicians from 3 or more specialties regarding patients problem, building trust between patients, their physicians and health care systems, thoughtful evaluation with exclusion of worrisome diagnosis, apply evidence-based information with effective risk communication, negotiating management strategies with patient and establishing regular follow-up with personalized feedback. (- 245 words).

Disentangling the Relationship between Physician and Organizational Performance: A Signal Detection Approach

Background. In previous research, we employed a signal detection approach to measure the performance of general practitioners (GPs) when deciding about urgent referral for suspected lung cancer. We also explored associations between provider and organizational performance. We found that GPs from practices with higher referral positive predictive value (PPV; chance of referrals identifying cancer) were more reluctant to refer than those from practices with lower PPV. Here, we test the generalizability of our findings to a different cancer. Methods. A total of 252 GPs responded to 48 vignettes describing patients with possible colorectal cancer. For each vignette, respondents decided whether urgent referral to a specialist was needed. They then completed the 8-item Stress from Uncertainty scale. We measured GPs' discrimination (d') and response bias (criterion; c) and their associations with organizational performance and GP demographics. We also measured correlations of d' and c between the 2 studies for the 165 GPs who participated in both. Results. As in the lung study, organizational PPV was associated with response bias: in practices with higher PPV, GPs had higher criterion (b = 0.05 [0.03 to 0.07]; P < 0.001), that is, they were less inclined to refer. As in the lung study, female GPs were more inclined to refer than males (b = -0.17 [-0.30 to -0.105]; P = 0.005). In a mediation model, stress from uncertainty did not explain the gender difference. Only response bias correlated between the 2 studies (r = 0.39, P < 0.001). Conclusions. This study confirms our previous findings regarding the relationship between provider and organizational performance and strengthens the finding of gender differences in referral decision making. It also provides evidence that response bias is a relatively stable feature of GP referral decision making.

Risk assessment and antibiotic prescribing decisions in children presenting to UK primary care with cough: a vignette study

OBJECTIVES

The validated 'STARWAVe' (Short illness duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting) clinical prediction rule (CPR) uses seven variables to guide risk assessment and antimicrobial stewardship in children presenting with cough. We aimed to compare general practitioners' (GPs) risk assessments and prescribing decisions to those of STARWAVe and assess the influence of the CPR's clinical variables.

SETTING

Primary care.

PARTICIPANTS

252 GPs, currently practising in the UK.

DESIGN

GPs were randomly assigned to view four (of a possible eight) clinical vignettes online. Each vignette depicted a child presenting with cough, who was described in terms of the seven STARWAVe variables. Systematically, we manipulated patient age (20 months vs 5 years), illness duration (3 vs 6 days), vomiting (present vs absent) and wheeze (present vs absent), holding the remaining STARWAVe variables constant.

OUTCOME MEASURES

Per vignette, GPs assessed risk of hospitalisation and indicated whether they would prescribe antibiotics or not.

RESULTS

GPs overestimated risk of hospitalisation in 9% of vignette presentations (88/1008) and underestimated it in 46% (459/1008). Despite underestimating risk, they overprescribed: 78% of prescriptions were unnecessary relative to GPs' own risk assessments (121/156), while 83% were unnecessary relative to STARWAVe risk assessments (130/156). All four of the manipulated variables influenced risk assessments, but only three influenced prescribing decisions: a shorter illness duration reduced prescribing odds (OR 0.14, 95% CI 0.08 to 0.27, p<0.001), while vomiting and wheeze increased them (OR_vomit 2.17, 95% CI 1.32 to 3.57, p=0.002; OR_wheeze 8.98, 95% CI 4.99 to 16.15, p<0.001).

CONCLUSIONS

Relative to STARWAVe, GPs underestimated risk of hospitalisation, overprescribed and appeared to misinterpret illness duration (prescribing for longer rather than shorter illnesses). It is important to ascertain discrepancies between CPRs and current clinical practice. This has implications for the integration of CPRs into the electronic health record and the provision of intelligible explanations to decision-makers.

Clinical prioritisation questions: A novel assessment tool to encourage tolerance of uncertainty?

Uncertainty is a common and increasingly acknowledged problem in clinical practice. Current single best answer (SBA) style assessments test areas where there is one correct answer, and as the approach to assessment impacts on the approach to learning, these exams may poorly prepare our future doctors to handle uncertainty. We therefore, need to modify our approach to assessment to emphasize reasoning and introduce the possibility of more than one 'correct' answer. We have developed clinical prioritization questions (CPQs), a novel formative assessment tool in which students prioritize possible responses in order of likelihood. This assessment format was piloted with a group of medical students and evaluated in comparison with the more traditional SBA question format in a team-based learning setting. Students reported that they felt ongoing use would help improve their tolerance of uncertainty (p < 0.01). Furthermore, over 80% of students felt that CPQs were more reflective of real-life clinical practice. Group based discussions were significantly longer when answering CPQs (p < 0.01), suggesting they may promote richer discourse. CPQs may have a role in formative assessment to help equip students with the skills to cope with ambiguity and strengthen clinical reasoning and decision-making. Institutions may find them more practical to implement compared with other clinical reasoning assessment tools.

Tolerance of ambiguity and psychological well-being in medical training: A systematic review

CONTEXT

The prevalence of stress, burnout and mental health disorders in medical students and doctors is high. It has been proposed that there may be an association between levels of tolerance of ambiguity (ie an ability to tolerate a lack of reliable, credible or adequate information) in clinical work and psychological well-being within this population. The aims of this systematic review were: (i) to assess the nature and extent of the literature available, in order to determine if there is an association, and (ii) to develop a conceptual model proposing possible mechanisms to underpin any association, in order to inform subsequent research.

METHODS

MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched for articles published from inception to September 2018. Additional literature was identified by searching the reference lists of included articles, forward searches of included articles, hand searches of key journals and a grey literature search. Of the 671 studies identified, 11 met the inclusion criteria. A qualitative synthesis of included studies was performed.

RESULTS

All 11 included studies reported an association between a lower level of tolerance of ambiguity or uncertainty and reduced psychological well-being. Included studies were heterogeneous in terms of population and measurement approach, and were often of low methodological quality. Subsets of items from previously developed scales were often used without sufficient consideration of the impact of new combinations of items on scale validity. Similar scales were also scored inconsistently between studies, making comparison difficult.

CONCLUSIONS

There appears to be an association between tolerance of ambiguity and psychological well-being. This provides new opportunities to understand and prevent the development of stress, burnout and mental health disorders in medical students and doctors. The conceptual model developed provides a framework for future research, which we hope will prevent wasted research effort through duplication and promote higher methodological quality.

A randomized experimental study to assess the effect of language on medical students' anxiety due to uncertainty

Background Communication and handoff failures are common causes of diagnostic errors in hospital. Human quest for certainty can increase the likelihood of premature closure in decision-making, the most common phenomenon in misdiagnosis. Little research exists on whether language choice in handoffs affects physicians' sense of uncertainty. Methods Medical students from a large US medical school were randomized to receive one of four language variations describing a presumed diagnosis in hypothetical handoffs from emergency department (ED) to inpatient ward. The control language arm used the word 'diagnosis'; experimental arms replaced this word with either 'hypothesis', 'probability of 60%', or 'working diagnosis' with a short differential. Outcome measures were students' anxiety due to uncertainty (range 5-30; higher scores indicating higher stress from uncertainty) and clinical uncertainty about the ED provider's presumed diagnosis. Results Mean anxiety due to uncertainty was significantly higher in subjects receiving the 'hypothesis' language arm compared to those receiving the control 'diagnosis' language [19.2 (4.6) vs. 15.5 (3.4); p<0.008]. Differences between subjects who received the probability language [17.2 (5.8) vs. 15.5 (3.4); p=0.26] and 'working diagnosis' language [16 (5) vs. 15.5 (3.4); p=0.69] were not statistically significant. There was no difference in items assessing clinical uncertainty after each scenario. Conclusions The word 'hypothesis' increased anxiety due to uncertainty compared to the word 'diagnosis', but did not change assessments of clinical uncertainty. Further research is needed to assess how use of language in clinical handoffs may influence perceptions and anxiety related to uncertainty and whether optimal language can be identified that leads to recognition of uncertainty without maladaptive stress or anxiety due to uncertainty.

Factors associated with therapeutic inertia among pharmacists caring for people with multiple sclerosis

INTRODUCTION

Pharmacists play a critical role on therapeutic decisions in multiple sclerosis (MS) care. Therapeutic inertia (TI) is defined as the lack of treatment initiation or escalation when there was evidence of clinical and radiological disease activity. The aim of this study was to assess factors associated with TI among pharmacists involved in MS care.

METHODS

A multicenter, non-interventional, cross-sectional study involving hospital pharmacists in Spain was conducted. Participants answered questions regarding their standard practice, risk preferences, and management of nine simulated MS case-scenarios. We created a score defined as the number of case-scenarios that fit the TI criteria over the total number of presented cases (score range from 0-6). Similarly, an optimal treatment score (OTS) was created to determine the degree of appropriate pharmacological decisions (ranging from 0-lowest to 9-highest). Candidate predictors of TI included demographic data, practice setting, years of practice, MS expertise, number of MS patients managed at hospital/year, participation in MS clinical trials, and participants' risk preferences.

RESULTS

Overall, 65 pharmacists initiated and completed the study (response rate: 45.5%). The mean age was 43.5 ± 7.8 years and 67.1% were female. Forty-two (64.6%) participants had specialization in MS management. Overall, the mean TI score was 3.4 ± 1.1. Of 390 individual responses, 224 (57.4%) met the TI criteria. All participants failed to recommend treatment escalation in at least one of the six case-scenarios. The mean OTS was 4.1 ± 1.4. Of 585 individual responses, 264 (45.1%) met the optimal choice criteria. Only 40% of participants (23/65) made five or more optimal treatment choices. Lower experience in dispensing MS drugs and lack of specialization in MS were the most common factors associated with TI and optimal management. The multivariable analysis revealed that more years of experience (p = 0.03), being a co-author of a peer-reviewed publication (p = 0.03), and specialization in MS (p = 0.017) were associated with lower TI scores (adjusted R² = 0.23).

CONCLUSION

Therapeutic inertia was observed in all pharmacist participants, affecting over fifty percent of MS treatment choices. Continuing education and specialization in MS may facilitate therapeutic decisions in MS care.

'We don't know for sure': discussion of uncertainty concerning multigene panel testing during initial cancer genetic consultations

Pre-test counseling about multigene panel testing involves many uncertainties. Ideally, counselees are informed about uncertainties in a way that enables them to make an informed decision about panel testing. It is presently unknown whether and how uncertainty is discussed during initial cancer genetic counseling. We therefore investigated whether and how counselors discuss and address uncertainty, and the extent of shared decision-making (SDM), and explored associations between counselors’ communication and their characteristics in consultations on panel testing for cancer. For this purpose, consultations of counselors discussing a multigene panel with a simulated patient were videotaped. Simulated patients represented a counselee who had had multiple cancer types, according to a script. Before and afterwards, counselors completed a survey. Counselors’ uncertainty expressions, initiating and the framing of expressions, and their verbal responses to scripted uncertainties of the simulated patient were coded by two researchers independently. Coding was done according to a pre-developed coding scheme using The Observer XT software for observational analysis. Additionally, the degree of SDM was assessed by two observers. Correlation and regression analyses were performed to assess associations of communicated uncertainties, responses and the extent of SDM, with counselors’ background characteristics. In total, twenty-nine counselors, including clinical geneticists, genetic counselors, physician assistants-in-training, residents and interns, participated of whom working experience varied between 0 and 25 years. Counselors expressed uncertainties mainly regarding scientific topics (94%) and on their own initiative (95%). Most expressions were framed directly (77%), e.g. We don’t know, and were emotionally neutral (59%; without a positive/negative value). Counselors mainly responded to uncertainties of the simulated patient by explicitly referring to the uncertainty (69%), without providing space for further disclosure (66%). More experienced counselors provided less space to further disclose uncertainty (p < 0.02), and clinical geneticists scored lower on SDM compared with other types of counselors (p < 0.03). Our findings that counselors mainly communicate scientific uncertainties and use space-reducing responses imply that the way counselors address counselees’ personal uncertainties and concerns during initial cancer genetic counseling is suboptimal.

Communicating uncertainties when disclosing diagnostic test results for (Alzheimer's) dementia in the memory clinic: The ABIDE project

Background

The development of novel diagnostics enables increasingly earlier diagnosis of Alzheimer's disease (AD). Timely diagnosis may benefit patients by reducing their uncertainty regarding the cause of symptoms, yet does not always provide patients with the desired certainty.

Objective

To examine, using both quantitative and qualitative methods, uncertainty communicated by memory clinic clinicians in post‐diagnostic testing consultations with patients and their caregivers.

Methods

First, we identified all uncertainty expressions of 22 clinicians in audiotaped post‐diagnostic testing consultations with 78 patients. Second, we statistically explored relationships between patient/clinician characteristics and uncertainty expressions. Third, the transcribed uncertainty expressions were qualitatively analysed, determining the topic to which they pertained, their source and initiator/elicitor (clinicians/patients/caregivers).

Results

Within 57/78 (73%) consultations, clinicians expressed in total 115 uncertainties, of which 37% elicited by the patient or caregiver. No apparent relationships were found between patient/clinician characteristics and whether or not, and how often clinicians expressed uncertainty. Uncertainty expressions pertained to ten different topics, most frequently patient's diagnosis and symptom progression. Expressed uncertainty was mostly related to the unpredictability of the future and limits to available knowledge.

Discussion and conclusions

The majority of clinicians openly discussed the limits of scientific knowledge and diagnostic testing with patients and caregivers in the dementia context. Noticeably, clinicians did not discuss uncertainty in about one quarter of consultations. More evidence is needed on the beneficial and/or harmful effects on patients of discussing uncertainty with them. This knowledge can be used to support clinicians to optimally convey uncertainty and facilitate patients' uncertainty management.

Cascades of Care After Incidental Findings in a US National Survey of Physicians

IMPORTANCE

Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally.

OBJECTIVE

To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians.

DESIGN, SETTING, AND PARTICIPANTS

Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019.

MAIN OUTCOMES AND MEASURES

Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades.

RESULTS

This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions.

CONCLUSIONS AND RELEVANCE

The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Factors Associated With the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke

Background and Purpose—

Little is known about the real-life factors that clinicians use in selection of patients that would receive endovascular treatment (EVT) in the real world. We sought to determine patient, practitioner, and health system factors associated with therapeutic decisions around endovascular treatment.

Methods—

We conducted a multinational cross-sectional web-based study comprising of 607 clinicians and interventionalists from 38 countries who are directly involved in acute stroke care. Participants were randomly allocated to 10 from a pool of 22 acute stroke case scenarios. Each case was classified as either Class I, Class II, or unknown evidence according to the current guidelines. We used logistic regression analysis applying weight of evidence approach. Main outcome measures were multilevel factors associated with EVT, adherence to current EVT guidelines, and practice gaps between current and ideal practice settings.

Results—

Of the 1330 invited participants, 607 (45.6%) participants completed the study (53.7% neurologists, 28.5% neurointerventional radiologists, 17.8% other clinicians). The weighed evidence approach revealed that National Institutes of Health Stroke Scale (34.9%), level of evidence (30.2%), ASPECTS (Alberta Stroke Program Early CT Score) or ischemic core volume (22.4%), patient’s age (21.6%), and clinicians’ experience in EVT use (19.3%) are the most important factors for EVT decision. Of 2208 responses that met Class I evidence for EVT, 1917 (86.8%) were in favor of EVT. In case scenarios with no available guidelines, 1070 of 1380 (77.5%) responses favored EVT. Comparison between current and ideal practice settings revealed a small practice gap (941 of 6070 responses, 15.5%).

Conclusions—

In this large multinational survey, stroke severity, guideline-based level of evidence, baseline brain imaging, patients’ age and physicians’ experience were the most relevant factors for EVT decision-making. The high agreement between responses and Class I guideline recommendations and high EVT use even when guidelines were not available reflect the real-world acceptance of EVT as standard of care in patients with disabling acute ischemic stroke.

Implementation Research on Shared Decision Making in Primary Care: Inventory of Intracluster Correlation Coefficients

Background. Cluster randomized trials are important sources of information on evidence-based practices in primary care. However, there are few sources of intracluster correlation coefficients (ICCs) for designing such trials. We inventoried ICC estimates for shared decision-making (SDM) measures in primary care. Methods. Data sources were studies led by the Canada Research Chair in Shared Decision Making and Knowledge Transition. Eligible studies were conducted in primary care, included at least 2 hierarchical levels, included SDM measures for individual units nested under any type of cluster (area, clinic, or provider), and were approved by an ethics committee. We classified measures into decision antecedents, decision processes, and decision outcomes. We used Bayesian random-effect models to estimate mode ICCs and the 95% highest probability density interval (HPDI). We summarized estimates by calculating median and interquartile range (IQR). Results. Six of 14 studies were included. There were 97 ICC estimates for 17 measures. ICC estimates ranged from 0 to 0.5 (median, 0.03; IRQ, 0-0.07). They were higher for process measures (median, 0.03; IQR, 0-0.07) than for antecedent measures (0.02; 0-0.07) or outcome measures (0.02; 0-0.06), for which, respectively, "decisional conflict" (mode, 0.48; 95% HPDI, 0.39-0.57), "reluctance to disclose uncertainty to patients" (0.5; 0.11-0.89), and "quality of the decision" (0.45; 0.14-0.84) had the highest ICCs. ICCs for provider-level clustering (median, 0.06; IQR, 0-0.13) were higher than for other levels. Limitations. This convenience sample of studies may not reflect all potential ICC ranges for primary care SDM measures. Conclusions. Our inventory of ICC estimates for SDM measures in primary care will improve the ease and accuracy of power calculations in cluster randomized trials and inspire its further expansion in SDM contexts.

Comparison of Physician Therapeutic Inertia for Management of Patients With Multiple Sclerosis in Canada, Argentina, Chile, and Spain

IMPORTANCE

There is growing interest in understanding and addressing factors that govern the decision-making process in multiple sclerosis (MS) care. Therapeutic inertia (TI) is the failure to escalate therapy when goals are unmet. Limited data are available on the prevalence of TI and factors affecting therapeutic decisions in the management of patients with MS worldwide.

OBJECTIVES

To compare TI across 4 countries (Canada, Argentina, Chile, and Spain) and to identify factors contributing to TI.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study conducted between July 10, 2017, and May 4, 2018. Participants were exposed to behavioral experiments in which instruments were used to assess their risk preferences (eg, aversion to ambiguity) and therapeutic decisions in 10 simulated MS case scenarios. Mixed-effects linear and logistic regression analyses were performed to determine the association between the participants' baseline characteristics and TI. The association of unmeasured confounders was assessed by the E-value and a bootstrapping analysis. This multicenter study included neurologists practicing at academic and community centers in Canada, Argentina, Chile, and Spain who make therapeutic decisions for patients with MS.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence of TI. The TI score was calculated by dividing the number of case scenarios in which participants showed TI by the number of case scenarios that measured TI. Higher TI scores indicated greater degrees of TI. The secondary outcome was the identification of factors that contributed to TI.

RESULTS

Of 300 neurologists with expertise in MS care who were invited to be part of the study, 226 (75.3%) agreed to participate. Among those who initially showed interest in participating, 195 physicians (86.3%) completed the study, while 31 did not. The mean (SD) age of participants was 43.3 (11.2) years; 52.3% were male. Therapeutic inertia was present in 72.8% (142 of 195) of participants, leading to suboptimal decisions in 20.4% (318 of 1560) of case scenarios. The prevalence of TI among the Canadian group was the lowest compared with the other 3 countries (60.0% [33 of 55] vs 77.9% [109 of 140]; P = .01). For the primary outcome, the TI score in the Canadian group (mean [SD], 0.98 [1.15]) was significantly lower compared with groups from other countries (mean [SD], 1.70 [1.43] for Argentina, 2.24 [1.54] for Chile, and 2.56 [1.64] for Spain) (P = .001). The mixed-effects linear models revealed that participants from Argentina, Chile, and Spain (combined) had higher TI scores compared with their Canadian counterparts (β coefficient, 0.90; 95% CI, 0.52-1.28; P < .001). A higher number of patients with MS per week (OR, 0.44; 95% CI, 0.22-0.88), years of practice (OR, 0.93; 95% CI, 0.86-0.99), and participation from Canada (OR, 0.47; 95% CI, 0.23-0.96) were associated with a lower likelihood of TI. Aversion to ambiguity was associated with a 2-fold higher likelihood of TI (OR, 2.25; 95% CI, 1.02-5.00). All 95% CIs of the β coefficients of covariates were lower than the E-value of 2.35, making it unlikely for the results to be due to the association of unmeasured confounders.

CONCLUSIONS AND RELEVANCE

This study showed that Canadian participants had the lowest prevalence and magnitude of TI. Higher TI scores were associated with a lower expertise in MS care and with a greater tendency for aversion to ambiguity.

Non-technical attributes and surgical experience: A cross-sectional study comparing communication styles and attitudes in surgical staff, trainees and applicants

BACKGROUND

This monocentric study aimed to explore whether key non-technical attributes can be reliably measured in a mixed population of candidates applying for surgical training, surgical trainees and staff and to identify any differences between these groups.

MATERIALS & METHODS

Candidates applying for surgical training, surgical trainees and staff from four surgical specialties (general surgery, orthopedics, plastic surgery or urology) at a tertiary academic teaching hospital were all sent an online self-report questionnaire. The Communication Styles Inventory (CSI, 96 items) was used to assess a six-dimensional behavioral model of participant communication styles (expressiveness, preciseness, verbal aggressiveness, questioningness, emotionality and impression manipulativeness). Attitudes toward uncertainty and risks were assessed with the Physicians' Reaction toward Uncertainty (PRU, 15 items) and Physician Risk Attitudes (PRA, 6 items) scales respectively. Data was encoded and analyzed using parametric testing.

RESULTS

The questionnaire was completed by 177 participants (110 candidates; 42 trainees; 25 staff). All scales had very good internal consistency (Cronbach's alpha >0.80). After controlling for gender-based differences, surgical candidates scored significantly higher on 'expressiveness' (P = 0.012) and were significantly less risk-averse (P = 0.006) than trainees and staff. Surgical trainees scored lowest on the CSI 'questioningness' subscale (P = 0.019) and had significantly more difficulties dealing with uncertainty, characterized by their highest scores on the 'concern about bad outcome' (P = 0.021) and reluctance to disclose uncertainty to patients' (P = 0.05) subscales. Multiple subscales revealed gender-based differences in candidate and trainee groups, which were not noted for surgical staff.

CONCLUSIONS

Meaningful differences in non-technical attributes of surgical staff, trainees and candidates have been identified, which may be explained by differences in clinical experience and learning and may suggest that these develop over time. Further research on assessment of non-technical attributes during surgical selections and the role of both technical and non-technical attributes in surgery at large is needed.

Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England

Background

Risk aversion among junior doctors that manifests as greater intervention (ordering of tests, diagnostic procedures and so on) has been proposed as one of the possible causes for increased pressure in emergency departments (EDs). Here we tested the prediction that doctors with more experience would be more tolerant of uncertainty and therefore less risk-averse in decision making.

Methods

In this cross-sectional, vignette-based study, doctors working in three EDs were asked to complete a questionnaire measuring experience (length of service in EDs), reactions to uncertainty (Gerrity et al, 1995) and risk aversion (responses about the appropriateness of patient management decisions).

Results

Data from 90 doctors were analysed. Doctors had worked in the ED for between 5 weeks and 21 years. We found a large association between experience and risk aversion so that more experienced clinicians made less risk-averse decisions (r=0.47, p<0.001). We also found a large association between experience and reactions to uncertainty (r=−0.50, p<0.001), with more experienced doctors being much more at ease with uncertainty. Mediation analyses indicated that tolerance of uncertainty partially mediated the relationship between experience and lower risk aversion, explaining about a quarter of the effect.

Conclusion

While we might be tempted to conclude from this research that experience and the ability to tolerate uncertainty lead to positive outcomes for patients (less risk-averse management strategies and higher levels of safety netting), what we are unable to conclude from this design is that these less risk-averse strategies improve patient safety.

Referral Decision Making of General Practitioners: A Signal Detection Study

BACKGROUND

Signal detection theory (SDT) describes how respondents categorize ambiguous stimuli over repeated trials. It measures separately "discrimination" (ability to recognize a signal amid noise) and "criterion" (inclination to respond "signal" v. "noise"). This is important because respondents may produce the same accuracy rate for different reasons. We employed SDT to measure the referral decision making of general practitioners (GPs) in cases of possible lung cancer.

METHODS

We constructed 44 vignettes of patients for whom lung cancer could be considered and estimated their 1-year risk. Under UK risk-based guidelines, half of the vignettes required urgent referral. We recruited 216 GPs from practices across England. Practices differed in the positive predictive value (PPV) of their urgent referrals (chance of referrals identifying cancer) and the sensitivity (chance of cancer patients being picked up via urgent referral from their practice). Participants saw the vignettes online and indicated whether they would refer each patient urgently or not. We calculated each GP's discrimination ( d ') and criterion ( c) and regressed these on practice PPV and sensitivity, as well as on GP experience and gender.

RESULTS

Criterion was associated with practice PPV: as PPV increased, GPs' c also increased, indicating lower inclination to refer ( b = 0.06 [0.02-0.09]; P = 0.001). Female GPs were more inclined to refer than male GPs ( b = -0.20 [-0.40 to -0.001]; P = 0.049). Average discrimination was modest ( d' = 0.77), highly variable (range, -0.28 to 1.91), and not associated with practice referral performance.

CONCLUSIONS

High referral PPV at the organizational level indicates GPs' inclination to avoid false positives, not better discrimination. Rather than bluntly mandating increases in practice PPV via more referrals, it is necessary to increase discrimination by improving the evidence base for cancer referral decisions.