Twelve tips for thriving in the face of clinical uncertainty

Systematic Search and Scoping Review of Physicians' Intolerance of Uncertainty and Medical Decision-Making Uncertainties During the COVID-19 Pandemic: A Summary of the Literature and Directions for Future Research

Pandemic-related uncertainties and intolerance of uncertainty (IU) could negatively affect physicians' well-being and functioning, being associated with experiences of distress and problematic decision-making processes. To summarize the available quantitative and qualitative evidence of physicians' IU and decisional uncertainty during COVID-19 and problems associated with it, a systematic search was conducted to identify all relevant articles describing physician uncertainty with regard to medical decision making and well-being in COVID-19 pandemic conditions. Medical, psychological, and preprint databases were searched. Ten articles met all eligibility criteria, with eight describing quantitative and two describing qualitative research outcomes, assessed primarily in European regions and via online surveys. Associations between IU and symptoms of poor mental health and mental health risk factors were widespread, but inconsistencies emerged. Qualitative studies emphasized decisional uncertainty as a stressor for physicians, and quantitative studies suggest it may have fostered more unproven treatment choices. While the prevalence and impact of physician uncertainty under COVID-19 conditions requires further investigation, sighting available literature indicates that IU coincided with experiences of poor mental health and, at least towards the beginning of the pandemic, with willingness to endorse unproven treatments. Efforts to reduce uncertainty-related problems for physicians seem warranted, for example, through normalizing experiences of uncertainty or reducing avoidable uncertainty through maintaining open and timely communication channels.

Improving communication of diagnostic uncertainty to families of hospitalized children

OBJECTIVES

Diagnostic uncertainty is not reliably communicated to patients and caregivers. This study aims to identify barriers and facilitators to effective communication of diagnostic uncertainty, including development of potential tools and strategies for improvement, as perceived by healthcare professionals and caregivers.

METHODS

We completed structured interviews with providers and caregivers of hospitalized children with uncertain diagnoses (UD). The interview guides addressed barriers to communication, key components for communication of uncertainty, and qualities of effective communication. The interviews concluded with respondents prioritizing potential interventions to improve communication of uncertainty. Interviews were audio recorded, transcribed, and independently analyzed by two team members to identify common themes.

RESULTS

Ten provider and five caregiver interviews were conducted. Common barriers to communication of uncertainty included time constraints, language barriers, and lack of clear definition of UD. Caregiver suggestions for improvement included sharing expectations of the diagnostic process and use of both written and visual communication tools. Interview respondents favored interventions of a sign summarizing the key components of diagnostic uncertainty for display in patient rooms and a structured diagnostic pause during daily rounds.

CONCLUSIONS

We identified several potential interventions that may enhance communication of diagnostic uncertainty and better engage patients and caregivers in the diagnostic process.

Navigating Uncertainty in Clinical Practice: A Structured Approach

The practice of clinical medicine is imbued with uncertainty. The ways in which clinicians and patients think about, communicate about, and act within situations of heightened uncertainty can have significant implications for the therapeutic alliance and for the trajectory and outcomes of clinical care. Despite this, there is limited guidance about the best methods for physicians to recognize, acknowledge, communicate about, and manage uncertainty in clinical settings. In this paper, we propose a structured approach for discussing and managing uncertainty within the context of a clinician-patient relationship. The approach involves four steps: Recognize, Acknowledge, Partner, and Seek Support (i.e., the RAPS framework). The approach is guided by existing literature on uncertainty as well as our own experience as clinicians working at different stages of career. We define each component of the approach and present sample language and actions for how to implement it in practice. Our aim is to empower clinicians to regard situations of high uncertainty as an opportunity to deepen the therapeutic alliance with the patient, and simultaneously to grow and learn as practitioners.

Uncertainty in serious illness: A national interdisciplinary consensus exercise to identify clinical research priorities

BACKGROUND

Serious illness is characterised by uncertainty, particularly in older age groups. Uncertainty may be experienced by patients, family carers, and health professionals about a broad variety of issues. There are many evidence gaps regarding the experience and management of uncertainty.

AIM

We aimed to identify priority research areas concerning uncertainty in serious illness, to ensure that future research better meets the needs of those affected by uncertainty and reduce research inefficiencies.

METHODS

Rapid prioritisation workshop comprising five focus groups to identify research areas, followed by a ranking exercise to prioritise them. Participants were healthcare professionals caring for those with serious illnesses including geriatrics, palliative care, intensive care; researchers; patient/carer representatives, and policymakers. Descriptive analysis of ranking data and qualitative framework analysis of focus group transcripts was undertaken.

RESULTS

Thirty-four participants took part; 67% female, mean age 47 (range 33-67). The highest priority was communication of uncertainty, ranked first by 15 participants (overall ranking score 1.59/3). Subsequent priorities were: 2) How to cope with uncertainty; 3) healthcare professional education/training; 4) Optimising clinical approaches to uncertainty; and 5) exploring in-depth experiences of uncertainty. Research questions regarding optimal management of uncertainty were given higher priority than questions about experiences of uncertainty and its impact.

CONCLUSIONS

These co-produced, clinically-focused research priorities map out key evidence gaps concerning uncertainty in serious illness. Managing uncertainty is the most pressing issue, and researchers should prioritise how to optimally manage uncertainty in order to reduce distress, unlock decision paralysis and improve illness and care experience.

'Insight' in medical training: what, why, and how?

The term 'insight' is generically defined in English language as the ability to perceive deeper truths about people and situations. In clinical practice, patient insight is known to have important implications in treatment compliance and clinical outcomes, and can be assessed clinically by looking for the presence of illness awareness, correct attribution of symptoms to underlying condition, and acceptance of treatment. In this article, we suggest that cultivating insight is actually a highly important, yet often overlooked, component of medical training, which may explain why some consistently learn well, communicate effectively, and quickly attain clinical competency, while others struggle throughout their clinical training and may even be difficult to remediate. We herein define 'insight' in the context of medical training as having an astute perception of personal cognitive processes, motivations, emotions, and ability (strengths, weaknesses, and limitations) that should drive self-improvement and effective behavioural regulation. We then describe the utility of cultivating 'insight' in medical training through three lenses of (i) promoting self-regulated, lifelong clinical learning, (ii) improving clinical competencies and person-centred care, and (iii) enhancing physician mental health and well-being. In addition, we review educational pedagogies that are helpful to create a medical eco-system that promotes the cultivation of insight among its trainees and practitioners. Finally, we highlight several tell-tale signs of poor insight and discuss psychological and non-psychological interventions that may help those severely lacking in insight to become more amenable to change and remediation.

How should uncertainty about upcoming painful procedures be communicated? An experimental study into highly uncertain pain predictions

OBJECTIVE

Uncertainty is unavoidable in the context of painful medical procedures. It is important to investigate the impact of different ways of communicating uncertainty on upcoming pain.

METHODS

In our exploratory study, healthy participants (n = 30) were repeatedly presented with three highly uncertain pain predictions communicated by a hypothetical doctor. A direct statement of high uncertainty ("I don't know") was compared to more indirect predictions (social prediction: "It varies widely among people"; range prediction: "… not painful at all to very highly painful"), followed by individually calibrated electrical stimuli of non-, moderately, or very highly painful intensity.

RESULTS

The direct expression of uncertainty led to the most intense pain sensation (for moderately painful stimuli only), lowest and most certain pain expectations, lowest trust in the hypothetical doctor, and lowest feeling of being well-informed, especially as compared to the social prediction. No differential effects on anxiety were observed.

CONCLUSIONS

Expressing high uncertainty indirectly, with reference to the common experiences of others, may be beneficial for optimizing pain experiences and enhancing patients' trust in a medical professional.

PRACTICE IMPLICATIONS

Our findings inform on how high uncertainty about upcoming pain may impact patient and health outcomes, pointing to some advantages of indirect communication.

Impact of an online learning by concordance program on reflection

BACKGROUND

Learning by concordance (LbC) is a recent approach that introduces learners to the complexity and uncertainty of clinical practice. Some data on LbC suggest that it stimulates reflection in future clinicians. We developed an online LbC training program on electrocardiogram (ECG) interpretation in general practice at the University of Strasbourg, France, and conducted an exploratory qualitative study to document the impact of this ECG learning-by-concordance training program on reflection in participants.

METHODS

We created 18 clinical vignettes on ECG interpretation based on a review of the literature on frequent and serious cardiovascular diseases that can be identified using an ECG in general practice. The training program was delivered online to postgraduate general practice students in two faculties of medicine. We conducted a qualitative study based on thematic analysis of two focus groups and six individual interviews. Inductive and deductive coding were performed. The five major components of reflection in the Nguyen model were used in the deductive coding: (i) thoughts and actions, (ii) attentive, critical, exploratory, and iterative processes (ACEI), (iii) underlying conceptual frame, (iv) change and (v) self.

RESULTS

Two focus groups and six individual interviews were conducted. The qualitative analysis indicated 203 codes in the focus groups and 206 codes in the individual interviews, which were divided into five groups based on the components of reflection in the Nguyen model: (i) the self; (ii) attentive, critical, exploratory, and iterative interactions with (iii) one's thoughts and actions; and (iv) a view on both the change itself and (v) the underlying conceptual frame. Inductive coding revealed interesting insights into the impact of the identity of the panel members, the absence of a scoring system and the question of uncertainty in ECG reading.

CONCLUSIONS

This study supports the claim that the use of LbC in the context of ECG interpretation could foster reflection in future general practitioners. We discuss future research avenues on instructional design of LbC and reflection.

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

Purpose

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

Method

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

Results

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

Conclusions

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

Clinical Uncertainty Influences Antibiotic Prescribing for Upper Respiratory Tract Infections: A Qualitative Study of Township Hospital Physicians and Village Doctors in Rural Shandong Province, China

OBJECTIVE

This study aimed to explore how clinical uncertainty influences antibiotic prescribing practices among township hospital physicians and village doctors in rural Shandong Province, China.

METHODS

Qualitative semi-structured interviews were conducted with 30 township hospital physicians and 6 village doctors from rural Shandong Province, China. A multi-stage random sampling method was used to identify respondents. Conceptual content analysis together with Colaizzi's method were used to generate qualitative codes and identify themes.

RESULTS

Three final thematic categories emerged during the data analysis: (1) Incidence and treatment of Upper Respiratory Tract Infections (URTIs) in township hospitals and village clinics; (2) Antibiotic prescribing practices based on the clinical experience of clinicians; (3) Influence of clinical uncertainty on antibiotic prescribing. Respondents from both township hospitals and village clinics reported that URTIs were the most common reason for antibiotic prescriptions at their facilities and that clinical uncertainty appears to be an important driver for the overuse of antibiotics for URTIs. Clinical uncertainty was primarily due to: (1) Diagnostic uncertainty (establishing a relevant diagnosis is hindered by limited diagnostic resources and capacities, as well as limited willingness of patients to pay for investigations), and (2) Insufficient prognostic evidence. As a consequence of the clinical uncertainty caused by both diagnostic and prognostic uncertainty, respondents stated that antibiotics are frequently prescribed for URTIs to prevent both prolonged courses or recurrence of the disease, as well as clinical worsening, hospital admission, or complications.

CONCLUSION

Our study suggests that clinical uncertainty is a key driver for the overuse and misuse of prescribing antibiotics for URTIs in both rural township hospitals and village clinics in Shandong province, China, and that interventions to reduce clinical uncertainty may help minimize the unnecessary use of antibiotics in these settings. Interventions that use clinical rules to identify patients at low risk of complications or hospitalization may be more feasible in the near-future than laboratory-based interventions aimed at reducing diagnostic uncertainty.

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.

What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care

OBJECTIVE

Shared decision making (SDM) is infrequently seen in clinical practice despite four decades of efforts. We propose a need to explore what SDM asks from doctors in terms of enabling competencies and necessary, underlying qualities, and how these can be nurtured or suppressed in medical training.

DISCUSSION

Key SDM tasks call for doctors to understand communication and decision mechanisms to carry them out well, including reflecting on what they know and do not know, considering what to say and how, and listening unprejudiced to patients. Different doctor qualities can support accomplishing these tasks; humility, flexibility, honesty, fairness, self-regulation, curiosity, compassion, judgment, creativity, and courage, all relevant to deliberation and decision making. Patient deference to doctors, lack of supervised training opportunities with professional feedback, and high demands in the work environment may all inflate the risk of only superficially involving patients.

CONCLUSIONS

We have identified ten professional qualities and related competencies required for SDM, with each to be selected based on the specific situation. The competencies and qualities need to be preserved and nurtured during doctor identity building, to bridge the gap between knowledge, technical skills, and authentic efforts to achieve SDM.

The cognitive apprenticeship: advancing reasoning education by thinking aloud

Teaching clinical reasoning has long challenged educators because it requires familiarity with reasoning concepts, experience with describing thinking, and comfort with exposing uncertainty and error. We propose that teachers adopt the cognitive apprenticeship model and a method of disclosing uncertainty known as intellectual streaking. These approaches reflect a shift in the educator's mindset from transmitting medical knowledge to broadcasting cognition. We provide several examples to guide the adoption of these strategies and make recommendations for teachers and training programs to improve the teaching of clinical reasoning.

Teaching the science of uncertainty

As we increasingly acknowledge the ubiquitous nature of uncertainty in clinical practice (Meyer AN, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Counsel 2021;104:2606-15; Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011;31:828-38) and strive to better define this entity (Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2020; Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med 2018;33:103-15), as educators we should also design, implement, and evaluate curricula addressing clinical uncertainty. Although frequently encountered, uncertainty is often implicitly referred to rather than explicitly discussed (Gärtner J, Berberat PO, Kadmon M, Harendza S. Implicit expression of uncertainty - suggestion of an empirically derived framework. BMC Med Educ 2020;20:83). Increasing explicit discussion of - and comfort with -uncertainty has the potential to improve diagnostic reasoning and accuracy and improve patient care (Dunlop M, Schwartzstein RM. Reducing diagnostic error in the intensive care unit. Engaging. Uncertainty when teaching clinical reasoning. Scholar;1:364-71). Discussion of both diagnostic and prognostic uncertainty with patients is central to shared decision-making in many contexts as well, (Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med 2019;34:2586-91) from the outpatient setting to the inpatient setting, and from undergraduate medical education (UME) trainees to graduate medical education (GME) trainees. In this article, we will explore the current status of how the science of uncertainty is taught from the UME curriculum to the GME curriculum, and describe strategies how uncertainty can be explicitly discussed for all levels of trainees.

Fostering uncertainty tolerance in anatomy education: Lessons learned from how humanities, arts and social science (HASS) educators develop learners' uncertainty tolerance

Uncertainty tolerance, individuals' perceptions/responses to uncertain stimuli, is increasingly recognized as critical to effective healthcare practice. While the Covid-19 pandemic generated collective uncertainty, healthcare-related uncertainty is omnipresent. Correspondingly, there is increasing focus on uncertainty tolerance as a health professional graduate "competency," and a concomitant interest in identifying pedagogy fostering learners' uncertainty tolerance. Despite these calls, practical guidelines for educators are lacking. There is some initial evidence that anatomy education can foster medical students' uncertainty tolerance (e.g., anatomical variation and dissection novelty), however, there remains a knowledge gap regarding robust curriculum-wide uncertainty tolerance teaching strategies. Drawing upon humanities, arts and social sciences (HASS) educators' established uncertainty tolerance pedagogies, this study sought to learn from HASS academics' experiences with, and teaching practices related to, uncertainty pedagogy using a qualitative, exploratory study design. Framework analysis was undertaken using an abductive approach, wherein researchers oscillate between inductive and deductive coding (comparing to the uncertainty tolerance conceptual model). During this analysis, the authors analyzed ~386 min of data from purposively sampled HASS academics' (n = 14) discussions to address the following research questions: (1) What teaching practices do HASS academics' perceive as impacting learners' uncertainty tolerance, and (2) How do HASS academics execute these teaching practices? The results extend current understanding of the moderating effects of education on uncertainty tolerance and supports prior findings that the anatomy learning environment is ripe for supporting learner uncertainty tolerance development. This study adds to growing literature on the powerful moderating effect education has on uncertainty tolerance and proposes translation of HASS uncertainty tolerance teaching practices to enhance anatomy education.

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.

Informal and Incidental Learning in the Clinical Learning Environment: Learning Through Complexity and Uncertainty During COVID-19

In the time of the COVID-19 pandemic, where clinical environments are plagued by both uncertainty and complexity, the importance of the informal and social aspects of learning among health care teams cannot be exaggerated. While there have been attempts to better understand the nuances of informal learning in the clinical environment through descriptions of the tacit or hidden curriculum, incidental learning in medical education has only been partially captured in the research. Understood through concepts borrowed from the Cynefin conceptual framework for sensemaking, the early stages of the pandemic immersed clinical teams in complex and chaotic situations where there was no immediately apparent relationship between cause and effect. Health care teams had to act quickly amidst the chaos: they had to first act, make sense of, and respond with intentionality. Informal and incidental learning (IIL) emerged as a byproduct of acting with the tools and knowledge available in the moment. To integrate the informal, sometimes haphazard nature of emergence among health care teams, educators require an understanding of IIL. This understanding can help medical educators prepare health professions learners for the cognitive dissonance that accompanies uncertainty in clinical practice. The authors introduce IIL as an explanatory framework to describe how teams navigate complexity in the clinical learning environment and to better inform curricular development for health professions training that prepares learners for uncertainty. While further research in IIL is needed to illuminate tacit knowledge that makes learning explicit for all audiences in the health professions, there are opportunities to cultivate learners' skills in formal curricula through various learning interventions to prime them for IIL when they enter complex clinical learning environments.

"Unfortunately, I don't have an answer for you": How resident physicians communicate diagnostic uncertainty to patients during emergency department discharge

OBJECTIVE

To describe how emergency medicine resident physicians discuss diagnostic uncertainty during a simulated ED discharge discussion.

METHODS

A secondary content analysis of simulated clinical encounter audiotapes completed by emergency medicine residents across two sites.

RESULTS

When discussing lack of diagnosis, residents explained the evaluation revealed no cause for symptoms, noted concerning diagnoses that were excluded, and acknowledged both symptoms and patients' feelings. Residents used explicit and implicit language to discuss diagnostic uncertainty with similar frequency. Almost half of the residents discussed the ED role as focused on emergent illness to give patients context for their uncertain diagnoses. However, 28% of residents in this study did not discuss diagnostic uncertainty in any form. All residents provided reassurance.

CONCLUSION

Residents use a range of approaches to discuss diagnostic uncertainty with patients at the time of a simulated ED discharge, with some residents omitting discussion of uncertainty entirely.

PRACTICE IMPLICATIONS

These findings represent the current state of communication, which needs improvement. These findings do not immediately transfer to clinical practice recommendations, but rather support a need for both further study and development of formal communication training on this topic.

Developing and validating of the Clinical Uncertainty Measurement Questionnaire (CUMQ) among practicing physicians and clinical residents in Iran

BACKGROUND

Despite the fact that clinicians face uncertainty in their decisions, there is no comprehensive framework to measure it in medical practices which is the knowledge gap especially for Iran. Therefore, this study aimed to evaluate the reliability and validity of a Persian questionnaire which is designed to measure different determining aspects of uncertainty from clinical physicians' perspectives in Iran.

METHODS

Clinical Uncertainty Measurement Questionnaire (CUMQ) has been derived from a mixed method study since March 2019 to January 2021. To exclude raw items of the questionnaire, the literature was reviewed and in-depthinterviews were implemented with 24 residents,specialists and sub-specialists in all major clinical fields which resulted in the first theoretical uncertainty in clinical decision making framework. CUMQ content validity has been evaluated using content validity index (CVI) and content validity ratio (CVR). The structural validity of the questionnaire was assessed using confirmatory factor analysis and factor loading and t-value for each indicator of uncertainty is reported. Moreover, to analyze the research model we used the Partial Least Squares (PLS) technique using the SmartPLS software. Convergent (using Average Variance Extracted (AVEs) for each latent variable) and discriminant validity (using the criteria of Fornell and Larckerand cross loading) of the model was also evaluated. After that, the quality of the model was evaluated adjustment through predictive validity (Q²) and effect size (f²). In addition, the reliability was also assessed using Cronbach's alpha and composite reliability.

RESULTS

The CVR and CVI ranged from 0. 80 to 1. 00 which illustrates high content validity. Out of 30 items, 24 items had acceptable factor loading and remained in the questionnaire which have been categorized as five main clinical uncertainty dimensions; general determinants, individual determinants of the physician, individual determinants of patient, dynamics of medical sciences, diagnostic and instrumental limitations. The value of composite reliability and Cronbach's alpha for all dimensions were above the threshold value of 0. 7 and the reliability has been confirmed. As AVE values were greater than 0. 5, convergent validity is confirmed. The result of Fornell-Larcker and cross-loadings also indicated that discriminant validity is well established.

CONCLUSION

This CUMQ is as avalid and reliable instrument and a suitable tool to measure clinical uncertainty in the Iranian Medical community. However, the reliability of this questionnaire can be studied in other languages and in other countries.

Defining Student-as-Teacher Curricula in the Absence of National Guidelines: An Innovative Model

Teaching is a critical skill in the medical profession, yet has only recently gained recognition as a core skill for medical students and trainees. Student-as-teacher (SAT) programs provide medical students formal teaching instruction with opportunities for practice. While efforts to determine how SAT courses should be taught are ongoing, the authors' review of SAT programs in medical schools' curricula shows they are diverse and often developed by faculty and trainees who advocate for formal teacher training at their institutions, rather than by medical school leadership. Consequently, there is significant heterogeneity among known SAT programs with regard to content, format, and evaluation methods. As efforts are underway to create guidelines and competency frameworks for SAT programs, medical educators must engage in open and critical discussion about the optimal content and organization for SAT educational experiences, emphasizing outcomes-based value and curricular and experiential consistency across programs. The authors describe an innovative SAT elective at Harvard Medical School (HMS), discuss research supporting curricular content and decisions, and emphasize potential implications for the conception and implementation of SAT programs at other institutions. The HMS SAT course is a year-long, elective, longitudinal curriculum built on a community of practice model and comprising 5 key components: Fundamentals of Medical Education seminar series, teaching field experiences, teaching observations, final educational product, and self-reflection. This 5-component theoretically justified model covers essential topics of SAT programming, providing students a comprehensive educational skills training curriculum. Medical educators developing SAT courses must identify common core competencies and curricular activities to implement SAT programs informed by the perspective of local stakeholders and institutional needs. Further growth of SAT programs in medical education offers opportunities for collaboration and coordination among medical educators, institutions, and licensing and accreditation bodies, to further develop consistent guidelines for teaching medical education skills to future medical educators.

Factors Associated with Physician Tolerance of Uncertainty: an Observational Study

BACKGROUND

Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area.

OBJECTIVE

To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout.

DESIGN

Online confidential survey.

SETTING

The Massachusetts General Physicians Organization (MGPO).

PARTICIPANTS

All 2172 clinically active faculty in the MGPO.

MAIN MEASURES

We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics.

KEY RESULTS

Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90).

CONCLUSION

At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.

Enhancing the "What" and "Why" of the Pharmacists' Patient Care Process With the "How" of Clinical Reasoning

Objectives. Clinical reasoning is integral to the provision of patient-centered care as outlined in the Pharmacists' Patient Care Process (PPCP). However, the PPCP was not created to foster clinical reasoning in student pharmacists and cannot be the sole tool used to characterize or cultivate these skills. This article describes elements of clinical reasoning, the relationship between clinical reasoning and PPCP, and concepts from the clinical reasoning literature that should inform the teaching of clinical reasoning skills.Findings. Key elements of the PPCP were identified in clinical reasoning definitions, but differences emerged. The literature supports clinical reasoning as a bidirectional, fluid process that is highly collaborative. Effective clinical reasoning requires multiple types of "thinking," interaction with others and the environment, self-assessment, and a tolerance for nuance or ambiguity. Teaching strategies can be used in the didactic and experiential setting to target the cognitive and contextual factors associated with clinical reasoning.Summary. Educators should consult the literature to enhance our understanding of clinical reasoning in seeking to teach, model, and foster these skills in our students. Future scholarship should include the development of models to support clinical reasoning within the profession of pharmacy, adoption and experimentation with clinical reasoning teaching techniques, and valuation of the utility of various assessment tools and processes.

The anxiety of not knowing: Diagnosis uncertainty about COVID-19

The emergence and swift global spread of COVID-19 brought increased anxiety worldwide (Santabárbara et al. (Progress in Neuro-Psychopharmacology & Biological Psychiatry, 109, 110207, 2021)). Research regarding the COVID-19 outbreak addressed factors that contribute to anxiety people experienced as they tried to handle the changes in their lives associated with COVID-19 (Holmes et al. (The Lancet Psychiatry, 7(6), 547-560, 2020)). This paper focuses on diagnosis uncertainty as a particular source of anxiety. We use self-reported anxiety measures to understand how different stressors, and particularly how being sick or being unsure if one or one's close friends or relatives are sick, relate to overall anxiety levels. Five-hundred and thirty-three participants from a country with a stringent COVID-19 testing policy were surveyed in the spring of 2020 on various aspects of their anxiety and risk for depression, as well as on whether they or their friends or family had COVID-19. Analysis of survey results found that anxiety related to uncertainty regarding whether the survey responder or their friends or family were carrying COVID-19 may be even greater than fear of the virus itself. This paper discusses directional issues related to this finding and offers policy implications for decreasing anxiety during pandemics for certain types of communities. In addition to the main findings regarding diagnosis uncertainty and anxiety, this paper's results also indicate the importance of providing participants with an option for "not sure" in closed questions and imply the increased knowledge that can be gained by analyzing an unsure response independently of "yes" or "no".

Navigating the uncertainty of health advocacy teaching and evaluation from the trainee's perspective

BACKGROUND

There may be no competency more shrouded in uncertainty than health advocacy (HA), raising questions about the robustness of advocacy training in postgraduate medical education. By understanding how programs currently train HA, we can identify whether trainees' learning needs are being met.

METHODS

From 2017 to 2019, we reviewed curricular documents across nine direct-entry specialties at all Ontario medical schools, comparing content for the HA and communicator roles to delineate role-specific challenges. We then conducted semi-structured interviews with trainees (n = 9) and faculty (n = 6) to review findings and discuss their impact. Data were analyzed using thematic content analysis.

RESULTS

Curricular documents revealed vague objectives and ill-defined modes of assessment for both intrinsic roles. This uncertainty was perceived as more problematic for HA, in part because HA seemed both undervalued in, and disconnected from, clinical learning. Trainees felt that the onus was on them to figure out how to develop and demonstrate HA competence, causing many to turn their learning attention elsewhere.

DISCUSSION

Lack of curricular focus seems to create the perception that advocacy isn't valuable, deterring trainees-even those keen to become competent advocates-from developing HA skills. Such ambivalence may have troubling downstream effects for both patient care and trainees' professional development.

Towards a medical school curriculum for uncertainty in clinical practice

Uncertainty abounds in the clinical environment. Medical students, however, are not explicitly prepared for situations of uncertainty in clinical practice, which can cause anxiety and impact well-being. To address this gap, we sought to capture how students felt in various clinical scenarios and identify programs they found helpful as they worked through uncertainty in their clerkships to better inform curriculum that prepares them to acknowledge and navigate this uncertainty. This is an observational cross-sectional study of third-year medical students surveyed at the end of core clerkships. The survey consisted of the General Self-Efficacy (GSE) Scale and Intolerance of Uncertainty Scale (IUS). Items asked students to rate preparedness, confidence, and comfort with uncertainty in clinical practice. Items on curricular programs asked students to identify training that prepared them for uncertainty in clerkships, and examined correlations with specific clinical practice uncertainty domains (CPUDs). Spearman's rank-order correlation, Chi-Square, and ANOVA were used to analyze quantitative data. Open responses were analyzed using Braun and Clarke's Framework. Response rate was 98.9% (287/290). GSE was inversely correlated with IUS (p < 0.001). GSE was positively correlated with all CPUDs (p < 0.005). IUS had an inverse correlation with all CPUDs (p < 0.005). Pedagogies with statistically-significant relationships with preparing students for uncertainty, communicating and building relationships with patients during times of uncertainty, and overall well-being included: team debriefs, role plays, case- and team-based learning, story slams, and sharing narratives with peers and faculty (p < 0.05). Qualitatively, students appreciated storytelling, role-modeling of communication strategies, debriefing, and simulations. Strategically immersing specific educational formats into formal curriculum may help cultivate skills needed to prepare students for uncertainty. Clinical debriefs, interprofessional role plays, simulations, communications skills training, instructor emotional vulnerability, storytelling, and peer-to-peer conversations may have the most impact. Further study is required to evaluate their longitudinal impact.

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.

A scoping review of practice recommendations for clinicians' communication of uncertainty

BACKGROUND

Health-care providers increasingly have to discuss uncertainty with patients. Awareness of uncertainty can affect patients variably, depending on how it is communicated. To date, no overview existed for health-care professionals on how to discuss uncertainty.

OBJECTIVE

To generate an overview of available recommendations on how to communicate uncertainty with patients during clinical encounters.

SEARCH STRATEGY

A scoping review was conducted. Four databases were searched following the PRISMA-ScR statement. Independent screening by two researchers was performed of titles and abstracts, and subsequently full texts.

INCLUSION CRITERIA

Any (non-)empirical papers were included describing recommendations for any health-care provider on how to orally communicate uncertainty to patients.

DATA EXTRACTION

Data on provided recommendations and their characteristics (eg, target group and strength of evidence base) were extracted. Recommendations were narratively synthesized into a comprehensible overview for clinical practice.

RESULTS

Forty-seven publications were included. Recommendations were based on empirical findings in 23 publications. After narrative synthesis, 13 recommendations emerged pertaining to three overarching goals: (a) preparing for the discussion of uncertainty, (b) informing patients about uncertainty and (c) helping patients deal with uncertainty.

DISCUSSION AND CONCLUSIONS

A variety of recommendations on how to orally communicate uncertainty are available, but most lack an evidence base. More substantial research is needed to assess the effects of the suggested communicative approaches. Until then, health-care providers may use our overview of communication strategies as a toolbox to optimize communication about uncertainty with patients.

PATIENT OR PUBLIC CONTRIBUTION

Results were presented to stakeholders (physicians) to check and improve their practical applicability.

A research approach for co-designing education with healthcare consumers

CONTEXT

Community and consumer involvement in health professions education (HPE) is of growing interest among researchers and educators, particularly in preparing health care graduates to effectively learn from, and collaborate with, people with lived experience of health issues. However, to date there has been limited direction on methodological approaches to engage health care consumers in the research and co-design of HPE.

APPROACH

In this paper, we describe the background to our work with health care consumers including the five core principles for successful co-design (inclusive; respectful; participative; iterative; outcomes focused) and how they can be applied as a research approach in HPE. We introduce the use of arts and humanities-based teaching methodologies including engagement, meaning-making and translational education strategies to illustrate how this research approach has been applied to reframe mental health education and practice in Australia. Furthermore, we share some reflective insights on the opportunities and challenges inherent in using a co-design research approach in HPE.

CONCLUSIONS

For the consumer voice to be embedded across HPE, there needs to be a collective commitment to curriculum redesign. This paper advances our understandings of the educational research potential of working with health care consumers to co-design rich and authentic learning experiences in HPE. Co-design research approaches that partner with and legitimise health care consumers as experts by experience may better align education and health professional practice with consumers' actual needs, an important first step in transforming hierarchical health care relationships towards more humanistic models of care.

Consensus statement on the content of clinical reasoning curricula in undergraduate medical education

INTRODUCTION

Effective clinical reasoning is required for safe patient care. Students and postgraduate trainees largely learn the knowledge, skills and behaviours required for effective clinical reasoning implicitly, through experience and apprenticeship. There is a growing consensus that medical schools should teach clinical reasoning in a way that is explicitly integrated into courses throughout each year, adopting a systematic approach consistent with current evidence. However, the clinical reasoning literature is 'fragmented' and can be difficult for medical educators to access. The purpose of this paper is to provide practical recommendations that will be of use to all medical schools.

METHODS

Members of the UK Clinical Reasoning in Medical Education group (CReME) met to discuss what clinical reasoning-specific teaching should be delivered by medical schools (what to teach). A literature review was conducted to identify what teaching strategies are successful in improving clinical reasoning ability among medical students (how to teach). A consensus statement was then produced based on the agreed ideas and the literature review, discussed by members of the consensus statement group, then edited and agreed by the authors.

RESULTS

The group identified 30 consensus ideas that were grouped into five domains: (1) clinical reasoning concepts, (2) history and physical examination, (3) choosing and interpreting diagnostic tests, (4) problem identification and management, and (5) shared decision making. The literature review demonstrated a lack of effectiveness for teaching the general thinking processes involved in clinical reasoning, whereas specific teaching strategies aimed at building knowledge and understanding led to improvements. These strategies are synthesised and described.

CONCLUSION

What is taught, how it is taught, and when it is taught can facilitate clinical reasoning development more effectively through purposeful curriculum design and medical schools should consider implementing a formal clinical reasoning curriculum that is horizontally and vertically integrated throughout the programme.

Reducing Diagnostic Error in the Intensive Care Unit. Engaging Uncertainty When Teaching Clinical Reasoning

As medicine continues to advance with improvements in technology, factual information has become more easily available at the bedside. Nevertheless, diagnostic error remains a salient concern for the medical community and public. To address this problem, two fundamental characteristics of the physician remain important: curiosity and the ability to apply critical reasoning to solve problems, often in the setting of imperfect knowledge and uncertainty. Historically, the teaching and recall of factual information, illness scripts, and pattern recognition are emphasized early in medical education. Students are often left with the impression that there is a single correct answer for every question; discussions of uncertainty are rare. Consequently, discomfort with uncertainty is common among doctors. As attention to explicit teaching of clinical reasoning increases, one must consider how to incorporate uncertainty into that teaching and to transform the clinical learning environment to embrace uncertainty. The authors propose the use of several simple methods easily employed in the critical care setting to make uncertainty explicit by changing the language used for expressing differential diagnosis, incorporating probabilities into daily sign-outs, and by implementing inductive reasoning when teaching critical thinking to offer learners a strategy for working through unknown problems; these approaches may normalize uncertainty, improve comfort with it, and reduce the impact of cognitive bias in decision-making. Comfort with uncertainty may result not only in improved clinical experiences for learning by transforming a once negative cognitive experience to a positive one but also in reduced susceptibility to thinking errors.

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).

'GP Live'- recorded General Practice consultations as a learning tool for junior medical students faced with the COVID-19 pandemic restrictions

BACKGROUND

First year medical students value doctor and patient contact. However, it can be challenging to achieve positive exposure to primary care on a large scale. The COVID-19 pandemic has placed even greater pressure on placing students in General Practice (GP).

AIM

To assess the feasibility and acceptability of showing Year 1 medical students authentic recorded consultations between GPs and patients, and then explore what they gained from this.

METHOD

Using Panopto® Video Platform, we pre-recorded real Primary Care consultations, with patient and GP consent, which were then processed securely using the University of Aberdeen server. These were shown to all Year 1 medical students who immediately debriefed these consultations in small groups with a GP tutor. Subsequently two focus groups were held with 11 students to evaluate what they had learnt.

LEARNING OUTCOMES

The consultations were easy to record and play during the teaching session, although there were some issues with sound quality. All students in the focus groups enjoyed the experience. They gained new knowledge about the skills of GPs, and recognised GPs as positive role models. Students were able to identify a variety of communication and consultation skills used by the GP, which reinforced their teaching on these delivered elsewhere in the course.

CONCLUSION

Using pre-recorded consultations as a teaching tool is reproducible, time-efficient and beneficial to students. We propose that this model of using authentic 'live' interactions between GPs and patients represents a valuable undergraduate educational opportunity and could be utilised by medical schools internationally.

'It struck at the heart of who I thought I was': A meta-synthesis of the qualitative literature examining the experiences of people with multiple sclerosis

Background

People with multiple sclerosis (MS) have varied experiences and approaches to self‐management. This review aimed to explore the experiences of people with MS, and consider the implications of these experiences for clinical practice and research.

Methods

A meta‐synthesis of the qualitative literature examining experiences of people with MS was conducted using systematic searches of ProQuest, PubMed, CINAHL and PsycINFO. We incorporated feedback from team members with MS as expert patient knowledge‐users to capture the complex subjectivities of persons with lived experience responding to research on lived experience of the same disease.

Results

Of 1680 unique articles, 77 met the inclusion criteria. We identified five experiential themes: (a) the quest for knowledge, expertise and understanding, (b) uncertain trajectories (c) loss of valued roles and activities, and the threat of a changing identity, (d) managing fatigue and its impacts on life and relationships, and (f) adapting to life with MS. These themes were distributed across three domains related to disease (symptoms; diagnosis; progression and relapse) and two contexts (the health‐care sector; and work, social and family life).

Conclusion

The majority of people in the studies included in this review expressed a determination to adapt to MS, indicating a strong motivation for people with MS and clinicians to collaborate in the quest for knowledge. Clinicians caring for people with MS need to consider the experiential and social outcomes of this disease such as fatigue and the preservation of valued social roles, and incorporate this into case management and clinical planning.

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.