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Dudley-Javoroski S, Cooper CS, Jackson JB, Zorn A, Carter KD, Shields RK. Tolerance for Ambiguity: Correlations With Medical and Physical Therapy Student Traits and Experiences Within the Learning Environment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:644-653. [PMID: 38232084 DOI: 10.1097/acm.0000000000005631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
PURPOSE Health care professions trainees and clinicians who perceive ambiguous situations as sources of threat (low tolerance for ambiguity [TFA]) experience greater risk for mental health disorders and professional burnout. Physical therapists likely encounter substantial ambiguity because of the biopsychosocial nature of their main therapeutic strategies. The purpose of this study was to identify student traits and experiences within the learning environment that differentiate students with high and low TFA for medicine and physical therapy (PT), and to identify areas of interprofessional overlap and distinction. METHOD Graduation Questionnaire survey data from graduating PT (n = 2,727) and medical students (n = 33,159) from the 2019-2020 and 2020-2021 academic years were sorted according to student TFA score, and respondents in the highest and lowest TFA quartiles were retained for analysis. Difference-in-differences analysis was used to reduce the number of potential explanatory factors to a parimonious subset that was put into linear regression models. Inferential statistics were applied to all significant factors identified from the linear regression models. RESULTS For both professions, higher TFA was generally associated with more positive ratings of the learning environment (student-faculty interactions, faculty professionalism, satisfaction with career choice), lower experiences of exhaustion and disengagement (the 2 axes of academic burnout), and higher scores for the empathy domain of perspective taking. Uniquely for medical students, low TFA was associated with lower empathy scores and a lower degree of interest in working with underserved individuals. CONCLUSIONS Findings suggest that for both professions, high TFA corresponded with better ratings of the educational experience and with traits that are advantageous for patient-centered practice and occupational resilience. Interventions to cultivate TFA among health care trainees may be an important way to meet the growing demand for humanistic health care professionals who are prepared to meet society's complex needs.
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Kerr AM, Thompson CM, Stewart CA, Rakowsky A. "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. HEALTH COMMUNICATION 2023; 38:1054-1064. [PMID: 34702092 DOI: 10.1080/10410236.2021.1991637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
| | - Charee M Thompson
- Department of Communication, University of Illinois, Urbana-Champaign
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Lazarus MD, Gouda‐Vossos A, Ziebell A, Brand G. Fostering uncertainty tolerance in anatomy education: Lessons learned from how humanities, arts and social science (HASS) educators develop learners' uncertainty tolerance. ANATOMICAL SCIENCES EDUCATION 2023; 16:128-147. [PMID: 35114066 PMCID: PMC10078696 DOI: 10.1002/ase.2174] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Michelle D. Lazarus
- Centre for Human Anatomy EducationDepartment of Anatomy and Developmental BiologyFaculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
- Monash Centre for Scholarship in Health Education, Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - Amany Gouda‐Vossos
- Centre for Human Anatomy EducationDepartment of Anatomy and Developmental BiologyFaculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - Angela Ziebell
- School of Life and Environmental SciencesDeakin University Burwood CampusBurwoodVictoriaAustralia
| | - Gabrielle Brand
- Monash Centre for Scholarship in Health Education, Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
- School of Nursing and MidwiferyFaculty of Medicine, Nursing and Health SciencesMonash UniversityFrankstonVictoriaAustralia
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Geller G, Shin S, Goldberg H, Merritt MW. Capacity for wonder among medical students: Assessment and educational implications. MEDICAL TEACHER 2023; 45:68-72. [PMID: 35856837 DOI: 10.1080/0142159x.2022.2099260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The capacity for wonder (CfW) is a personal disposition related to lifelong learning and moral character development, two highly valued characteristics of health professionals. We previously developed and validated a CfW measure among college students. Here we describe how the scale performs among medical students. METHODS We invited all students at a top-tier U.S. medical school (N = 477) to participate in an online survey including the CfW measure, year in medical school, and demographics. We performed confirmatory factor analysis on the CfW measure and reassessed its reliability. RESULTS 276 students completed the survey for an overall response rate of 58%. Factor analysis resulted in a 10-item scale with an alpha of 0.79 and an eigen value of 3.57. Factor loadings ranged from 0.43 to 0.77. The mean total score was 39.3 (SD = 8.9) out of a possible high score of 60. Total scores varied by year in school with significantly lower scores among 2nd year students (32.9 vs. 41.5; p < 0.001). CONCLUSION We confirmed the reliability of a 10-item CfW scale in 4 cohorts of medical students. Results suggest that the 2nd year of medical school poses the greatest risk to students' capacity for wonder. Efforts should be made to understand this phenomenon and develop interventions to mitigate it. Future research should explore the validity of the CfW scale, its utility in evaluating interventions designed to cultivate the capacity for wonder, its applicability to other groups of health professionals, and its association with ethical decision-making and practice.
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Affiliation(s)
- Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Seonho Shin
- District of Columbia, Cambrium Assessment, Washington, DC, USA
| | - Harry Goldberg
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Maria W Merritt
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Ilgen JS, Watsjold BK, Regehr G. Is uncertainty tolerance an epiphenomenon? MEDICAL EDUCATION 2022; 56:1150-1152. [PMID: 36124815 DOI: 10.1111/medu.14938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Bjorn K Watsjold
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Glenn Regehr
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada
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Van Hooser J, Swanson S, Conway JM, Brown JT. Assessing pharmacy students' baseline tolerance for ambiguity, burnout, empathy, quality of life, and stress. CURRENTS IN PHARMACY TEACHING & LEARNING 2022; 14:966-971. [PMID: 36055705 DOI: 10.1016/j.cptl.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 06/23/2022] [Accepted: 07/13/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Several factors may affect student wellbeing, including tolerance for ambiguity, burnout, empathy, quality of life, and stress. A better understanding of how pharmacy students score on these scales relative to other health professional students could help educators and schools address and improve student wellbeing. The study objective was to determine a baseline measure of pharmacy student tolerance for ambiguity, burnout, empathy, quality of life, and stress. METHODS A voluntary survey including several assessment scales (Tolerance for Ambiguity, Oldenburg Burnout Inventory, Interpersonal Reactivity Index [empathy], Quality of Life Scale, and Perceived Stress Scale) was sent by email to all pharmacy students within a standalone college of pharmacy. RESULTS Two hundred thirty-one pharmacy students completed all aspects of the survey. Comparing each scale with sex, female students trended higher in Interpersonal Reactivity Index and scored significantly higher on the Oldenburg Burnout Inventory (disengagement), while male students scored significantly higher for Quality of Life. Fourth-year students scored significantly higher on the Tolerance for Ambiguity scale as compared to first- and second-year students and on the Quality of Life scale as compared with third-year students. Third-year students experienced the greatest levels of burnout. Differences were also noted based on students' anticipated area of practice (empathy) and desire to work with an underserved population (empathy and stress). CONCLUSIONS Pharmacy students' responses to the included scales varied greatly when considering various demographic parameters. The significant differences identified are illuminating and represent potential areas for curricular improvement, student support, and further study within pharmacy school curricula.
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Affiliation(s)
- Jared Van Hooser
- Pharmaceutical Care Learning Center - Duluth, University of Minnesota College of Pharmacy, 1110 Kirby Drive, Duluth, MN 55812, United States.
| | - Stephanie Swanson
- University of Minnesota College of Pharmacy, 308 Harvard St SE, Minneapolis, MN 55455, United States.
| | - Jeannine M Conway
- Associate Dean for Professional Education and Associate Professor, 308 Harvard St. SE, Minneapolis, MN 55455, United States.
| | - Jacob T Brown
- University of Minnesota College of Pharmacy, 1110 Kirby Drive, Duluth, MN 55812, United States.
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Spinelli C, Ibrahim M, Khoury B. Cultivating ambiguity tolerance through mindfulness: An induction randomized controlled trial. CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-021-02597-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Poluch M, Feingold-Link J, Papanagnou D, Kilpatrick J, Ziring D, Ankam N. Intolerance of Uncertainty and Self-Compassion in Medical Students: Is There a Relationship and Why Should We Care? JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2022; 9:23821205221077063. [PMID: 35602091 PMCID: PMC9118430 DOI: 10.1177/23821205221077063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Managing the uncertainty of clinical practice represents a significant source of stress for clinicians, including medical students transitioning into the clinical workplace. Self-compassion, a strategy to better cope with stress and burnout, may represent a skill that can be leveraged to better prepare learners for the uncertainty inherent in clinical practice. A negative correlation between intolerance of uncertainty and self-compassion has been demonstrated in undergraduate students and in the general population. An examination of this relationship in medical students may help inform future curricular development for addressing burnout in undergraduate medical education. We electronically administered the Intolerance of Uncertainty Short Scale and the Self-Compassion Short Form to 273 third-year medical students from a single institution and analyzed data via regression. A significant negative correlation was found between intolerance of uncertainty and self-compassion (p < 0.0001). Students with higher levels of self-compassion showed lower levels of intolerance of uncertainty. This is consistent with findings in other populations. Our findings offer a starting point for designing training experiences that strengthen student self-compassion to enhance their ability to reconcile the uncertainty they will encounter in clinical practice.
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Affiliation(s)
- Maria Poluch
- Maria Poluch, Thomas Jefferson University, Philadelphia, PA
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Pigg M, Brodén J, Fransson H, Vareman N. How do we and how should we deal with uncertainty in Endodontics? Int Endod J 2021; 55:282-289. [PMID: 34967026 PMCID: PMC9305865 DOI: 10.1111/iej.13679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022]
Abstract
In many clinical cases a dentist may feel certain when for example diagnosing, deciding on treatment, or assessing the prognosis—in other cases many dentists may feel a degree of doubt or uncertainty. This paper aims to explore the philosophical concept of uncertainty and its different dimensions, using the condition “persistent apical periodontitis associated with a previously root filled tooth” as an example. Acknowledging that uncertainty exists in any clinical situation can be perceived as uncomfortable, as some might regard it as a weakness. Whilst some types of uncertainty met in dental practice can be addressed and reduced, there are other types which are inevitable and must be accepted. To make sound decisions, it is pertinent that the dentist reflects on and values the consequences of uncertainty. In this paper, a conceptual model is presented by which the dentist can identify the type of uncertainty in a clinical case, making it possible to decide on a strategy on how to manage the uncertainty and its possible consequences, with the aim to support the dentist's care for their patients. The understanding that uncertainty exists and the ability to acknowledge and be comfortable with it when making decisions should be addressed throughout our professional career, and thus ought to be developed during undergraduate education. Some suggestions on how teachers could target this are given in the paper.
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Affiliation(s)
- Maria Pigg
- Department of Endodontics, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Joséphine Brodén
- Department of Oral Biology, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Helena Fransson
- Department of Endodontics, Faculty of Odontology, Malmö University, Malmö, Sweden
| | | | | | - Niklas Vareman
- Department of Medical Ethics, Lund University, Lund, Sweden
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Borracci RA, Ciambrone G, Arribalzaga EB. Tolerance for Uncertainty, Personality Traits and Specialty Choice Among Medical Students. JOURNAL OF SURGICAL EDUCATION 2021; 78:1885-1895. [PMID: 34001460 DOI: 10.1016/j.jsurg.2021.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/20/2021] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The objective was to explore the tolerance for uncertainty in its different aspects (risk, ambiguity and complexity) in medical students at different times of their careers, and to relate these tolerance levels with their predominant personality traits and specialty choices. A secondary objective was to build a hypothetical model aimed at explaining the potential relationships of dependency between gender, personality traits, tolerance for uncertainty and specialty choice using a structural equation modeling (SEM) analysis. DESIGN/SETTING/PARTICIPANTS A prospective cross-sectional study including two cohorts of second-year (n = 155) and sixth-year (n = 157) medical students was performed during 2017 at the Buenos Aires University School of Medicine. Both student cohorts completed instruments assessing tolerance for different types of uncertainty: (1) complexity (Tolerance for Ambiguity scale); (2) risk (Pearson Risk Attitude scale); and (3) ambiguity (Ambiguity Aversion in Medicine scale). Information on age, gender and specialty choice in sixth-year medical students was included, plus the Big Five Inventory-10 (BFI-10) personality test. RESULTS Sixth-year students showed significantly lower scores than second-year students at tolerance for complexity (p = 0.0003) and ambiguity (p = 0.008). Sixth-year students choosing a surgical specialty were associated with low tolerance for risk and ambiguity, and moderate for complexity. Conversely, students choosing a clinical specialty were related with high tolerance for risk, moderate for ambiguity, and low for complexity. Logistic regression analysis including the uncertainty questionnaires plus BFI-10 categories demonstrated that only the "neuroticism" personality trait was independently associated with a surgical specialty choice (OR: 1.31, 95%CI: 1.03-1.67). The final SEM that best represented the data showed good fit statistics: chi-square (p = 0.108), and RMSEA (p = 0.047). CONCLUSIONS Tolerance for uncertainty in its different dimensions was associated with personality traits and specialty choice among medical students. A SEM analysis could satisfactorily explain the hypothetical relationships of dependency between gender, personality traits, tolerance for uncertainty, and specialty choice.
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Affiliation(s)
- Raúl A Borracci
- School of Medicine, Buenos Aires University, Buenos Aires, Argentina; Medical Education Research Laboratory, Deutsches Hospital, Buenos Aires, Argentina.
| | - Graciana Ciambrone
- Medical Education Research Laboratory, Deutsches Hospital, Buenos Aires, Argentina
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Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2021; 27:1194-1204. [PMID: 33089607 DOI: 10.1111/jep.13503] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/21/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education. METHOD A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty. RESULTS Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education. CONCLUSION The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.
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Affiliation(s)
- Ciara Lee
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Katherine Hall
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Megan Anakin
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ralph Pinnock
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
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Gana W, Nkodo JA, Fougère B. Medical decision making during the COVID-19 epidemic: an opportunity to think how we think. Diagnosis (Berl) 2021; 8:400-401. [PMID: 33554520 DOI: 10.1515/dx-2020-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 12/15/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Wassim Gana
- Division of Geriatric Medicine, Tours University Hospital, Tours, France
| | - Jacques-Alexis Nkodo
- Division of Geriatric Medicine, Tours University Hospital, Tours, France.,University Psychiatric Clinic, Tours University Hospital, Tours, France
| | - Bertrand Fougère
- Division of Geriatric Medicine, Tours University Hospital, Tours, France.,Education, Ethics, Health (EA 7505), Tours University, Tours, France
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Reis-Dennis S, Gerrity MS, Geller G. Tolerance for Uncertainty and Professional Development: a Normative Analysis. J Gen Intern Med 2021; 36:2408-2413. [PMID: 33532966 PMCID: PMC7853704 DOI: 10.1007/s11606-020-06538-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/21/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Samuel Reis-Dennis
- Alden March Bioethics Institute, Albany Medical College, Albany, NY, USA
| | - Martha S Gerrity
- Division of General Medicine and Geriatrics, Oregon Health and Sciences University, OR, Portland, USA.
- Section of General Medicine, VA Portland Health Care System, OR, Portland, USA.
| | - Gail Geller
- Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, MD, Baltimore, USA
- School of Medicine, Johns Hopkins University, MD, Baltimore, USA
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Bradley CL, Schwartz SE, Cooper JB. Communicating definitive uncertainty: Teaching pharmacy students to say "I don't know". CURRENTS IN PHARMACY TEACHING & LEARNING 2021; 13:1032-1039. [PMID: 34294244 DOI: 10.1016/j.cptl.2021.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/29/2021] [Accepted: 06/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND PURPOSE Communicating uncertainty is an art requiring practice. The purpose of this study was to compare pedagogies for the instruction of pharmacy students in communicating definitive uncertainty. EDUCATIONAL ACTIVITY AND SETTING A case scenario featuring a busy physician asking a question without a definitive answer was directed to the pharmacy student using two pedagogies: (1) in-person standardized client and (2) virtual written case. Students provided self-assessments of their confidence in communicating uncertainty after completing the case utilizing a survey containing both rating scale questions and open-ended questions. Self-confidence within-group differences were compared using Wilcoxon signed-rank tests and between-group differences were compared using Mann-Whitney U tests. Responses to open-ended questions were descriptively analyzed for themes using qualitative assessment methods. FINDINGS Both the in-person standardized client (70 to 81, P ≤ .001) and the virtual written case (74 to 85, P ≤ .001) significantly increased students' self-rated confidence to verbalize "I don't know" to a healthcare provider. No significant differences were observed between the pedagogies. However, students who participated in the virtual written case mentioned a desire for "additional practice opportunities" more frequently than students who participated in the in-person standardized client. SUMMARY In-person standardized client and virtual written case are effective methods for increasing pharmacy student comfort with communicating definitive uncertainty. Further research is needed to instruct pharmacists in uncertainty communication.
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Affiliation(s)
- Courtney L Bradley
- High Point University Fred Wilson School of Pharmacy, 1 University Parkway, High Point, NC 27685, United States.
| | - Shaina E Schwartz
- High Point University Fred Wilson School of Pharmacy, 1 University Parkway, High Point, NC 27685, United States.
| | - Julie B Cooper
- High Point University Fred Wilson School of Pharmacy, 1 University Parkway, High Point, NC 27685, United States.
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Geller G, Grbic D, Andolsek KM, Caulfield M, Roskovensky L. Tolerance for Ambiguity Among Medical Students: Patterns of Change During Medical School and Their Implications for Professional Development. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1036-1042. [PMID: 33149092 DOI: 10.1097/acm.0000000000003820] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Tolerance for ambiguity (TFA) is important for physicians, with implications for ethical behavior and patient care. This study explores how medical students' TFA changes from matriculation to graduation and how change in empathy and openness to diversity are associated with this change. METHOD Data for students who took the Matriculating Student Questionnaire (MSQ) in 2013 or 2014 and the Medical School Graduation Questionnaire (GQ) in 2017 or 2018 were drawn from the Association of American Medical Colleges (n = 17,221). Both the MSQ and GQ included a validated TFA scale and a shortened version of the Interpersonal Reactivity Index; the MSQ also included an openness to diversity scale. Tercile groups were used to assess how TFA changed from the MSQ to GQ, and regression analyses were used to assess associations between change in TFA and openness to diversity and between change in TFA and change in empathy. RESULTS Mean TFA scores decreased (d = -.67) among students with the highest TFA at matriculation but increased (d = .60) among students with the lowest TFA at matriculation. Regression results showed that change in TFA was significantly and positively associated with change in empathy (beta = .05, P < .001) and that openness to diversity (as reported at matriculation) was significantly and positively associated with TFA at graduation (beta = .05, P < .001). CONCLUSIONS This is the first nationally representative study to suggest that medical students' TFA changes over time, but in different directions depending on TFA at matriculation. TFA over time was also associated with change in empathy and openness to diversity. Medical schools should consider strategies to assess TFA in their admissions processes and for cultivating TFA throughout the learning process.
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Affiliation(s)
- Gail Geller
- G. Geller is professor, Johns Hopkins University Berman Institute of Bioethics, School of Medicine, Bloomberg School of Public Health, and Department of Sociology, Johns Hopkins University, Baltimore, Maryland; ORCID: https://orcid.org/0000-0003-4856-1942
| | - Douglas Grbic
- D. Grbic is lead research analyst, Medical Education, Association of American Medical Colleges, Washington, DC
| | - Kathyrn M Andolsek
- K.M. Andolsek is professor of family medicine and community health, Duke University School of Medicine, Durham, North Carolina
| | - Marie Caulfield
- M. Caulfield is manager of applicant, student, and resident data, Data Operations and Services, Association of American Medical Colleges, Washington, DC
| | - Lindsay Roskovensky
- L. Roskovensky is lead research and data analyst, Data Operations and Services, Association of American Medical Colleges, Washington, DC
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Ilgen JS, Regehr G, Teunissen PW, Sherbino J, de Bruin ABH. Skeptical self-regulation: Resident experiences of uncertainty about uncertainty. MEDICAL EDUCATION 2021; 55:749-757. [PMID: 33527454 DOI: 10.1111/medu.14459] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Glenn Regehr
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
- School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Pim W Teunissen
- School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jonathan Sherbino
- McMaster Education Research, Innovation and Theory (MERIT) program, Faculty of Health Science, McMaster University, Hamilton, ON, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anique B H de Bruin
- School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Han PKJ, Strout TD, Gutheil C, Germann C, King B, Ofstad E, Gulbrandsen P, Trowbridge R. How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy. Med Decis Making 2021; 41:275-291. [PMID: 33588616 PMCID: PMC7985858 DOI: 10.1177/0272989x21992340] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/16/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. OBJECTIVES To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty. DESIGN Qualitative study using individual in-depth interviews. PARTICIPANTS Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital. MEASUREMENTS Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. RESULTS Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. CONCLUSIONS Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.
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Affiliation(s)
- Paul K. J. Han
- />Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA
- />Tufts University School of Medicine, Boston, MA, USA
| | - Tania D. Strout
- />Tufts University School of Medicine, Boston, MA, USA
- />Department of Emergency Medicine, Maine Medical Center, Portland, ME, USA
| | - Caitlin Gutheil
- />Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA
- />Tufts University School of Medicine, Boston, MA, USA
| | - Carl Germann
- />Tufts University School of Medicine, Boston, MA, USA
- />Department of Emergency Medicine, Maine Medical Center, Portland, ME, USA
| | - Brian King
- />Tufts University School of Medicine, Boston, MA, USA
- />Department of Medicine, Maine Medical Center, Portland, ME, USA
| | - Eirik Ofstad
- />Department of Medicine, Nordland Hospital Trust, Bodø, Norway
- />Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Pål Gulbrandsen
- />Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- />HØKH Research Center, Akershus University Hospital, Lørenskog, Norway
| | - Robert Trowbridge
- />Tufts University School of Medicine, Boston, MA, USA
- />Department of Medicine, Maine Medical Center, Portland, ME, USA
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Quinlan E, Schilder S, Deane FP. “This wasn’t in the manual”: a qualitative exploration of tolerance of uncertainty in the practicing psychology context. AUSTRALIAN PSYCHOLOGIST 2021. [DOI: 10.1080/00050067.2020.1829451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Elly Quinlan
- Discipline of Psychology, Australian College of Applied Psychology, Sydney, Australia
| | - Suzanne Schilder
- Discipline of Psychology, Australian College of Applied Psychology, Sydney, Australia
| | - Frank P. Deane
- Illawarra Institute for Mental Health, University of Wollongong, Wollongong, Australia
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From Jerseys to Scrubs: Is Sport Background Associated with Medical Students’ Tolerance of Ambiguity and Uncertainty? HEALTH PROFESSIONS EDUCATION 2020. [DOI: 10.1016/j.hpe.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Liu Y, Erath A, Salwi S, Sherry A, Mitchell MB. Alignment of Ethics Curricula in Medical Education: A Student Perspective. TEACHING AND LEARNING IN MEDICINE 2020; 32:345-351. [PMID: 32000533 DOI: 10.1080/10401334.2020.1717959] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Issue: Although there is consensus on the importance of including ethics in the medical school curriculum, there is wide variation in how this topic is taught. Recent literature also questions the effectiveness of current ethical teaching methods in changing student attitudes and future behavior. Furthermore, from the student perspective, there is a marked disconnect between the stated importance of and lack of effort in ethics courses. Evidence: Applying a student perspective of the hidden curriculum, as well as reviewing and applying insight from the available literature, we advocate for alignment of instructional design, content, and assessments. This article provides specific recommendations to increase student engagement in ethics courses and concludes by discussing whether a lack of engagement is attributable to intrinsic qualities of medical students in addition to pedagogical technique and educational setting and culture. Implications: This article has practical suggestions for medical educators to improve their ethics courses, leading to more well-rounded and thoughtful physicians.
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Affiliation(s)
- Yangzi Liu
- VUSM Medical Ethics, Law, & Policy Student Group, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alexandra Erath
- VUSM Medical Ethics, Law, & Policy Student Group, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Sanjana Salwi
- VUSM Medical Ethics, Law, & Policy Student Group, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alexander Sherry
- VUSM Medical Ethics, Law, & Policy Student Group, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Margaret B Mitchell
- VUSM Medical Ethics, Law, & Policy Student Group, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Gheihman G, Johnson M, Simpkin AL. Twelve tips for thriving in the face of clinical uncertainty. MEDICAL TEACHER 2020; 42:493-499. [PMID: 30912996 DOI: 10.1080/0142159x.2019.1579308] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Background: Effectively managing clinical uncertainty is increasingly recognized as a goal of medical education. Stress from uncertainty has been associated with depression and burnout in trainees and may also impact patient care. Despite its importance, however, strategies to embrace uncertainty in clinical practice are lacking.Aims: The literature on uncertainty in medicine was reviewed. Incorporating insights from faculty and students, 12 tips for healthcare educators to help themselves and others thrive in the face of clinical uncertainty were developed.Results: Educators will find the tips practical and easy to implement in their day-to-day interactions as clinicians and teachers. Tips are divided into tips for oneself; for implementing with students and trainees; and for implementing with patients and in healthcare systems.Conclusions: These tips can enhance healthcare professionals' and students' ability to thrive in the face of uncertainty. Strategies to embrace uncertainty are critical for ourselves, our trainees, our patients, and our healthcare systems.
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Affiliation(s)
| | - Mark Johnson
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA
| | - Arabella L Simpkin
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Pharmacology, University of Oxford, Oxford, UK
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Structured Interviewer Training for the Implementation of Standardized Behavioral Questions in Medical School Admissions. Simul Healthc 2020; 15:128-132. [PMID: 32235263 DOI: 10.1097/sih.0000000000000415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Platts-Mills TF, Nagurney JM, Melnick ER. Tolerance of Uncertainty and the Practice of Emergency Medicine. Ann Emerg Med 2019; 75:715-720. [PMID: 31874767 DOI: 10.1016/j.annemergmed.2019.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - Justine M Nagurney
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, and the Institute for Aging Research, Hebrew Senior Life, Boston, MA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, CT
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Tharenos CL, Hayden AM, Cook E. Resident Self-Portraiture: A Reflective Tool to Explore the Journey of Becoming a Doctor. THE JOURNAL OF MEDICAL HUMANITIES 2019; 40:529-551. [PMID: 30673926 DOI: 10.1007/s10912-018-9545-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This arts- based project creatively introduces residents to photography, self-portraiture and narratives to document the longitudinal journey of becoming a family physician. Visual arts and writing can foster reflection: an important skill to cultivate in developing physicians. Unfortunately, arts based programs are lacking in many residency programs. Tools and venues that nourish physician well being and resilience may be important in today's changing healthcare environment and epidemic of physician burnout. Residents created self-portraits with accompanying narratives throughout their three-year training. Analysis of the portraits and accompanying narratives completed the assessment. Residents created a body of work that includes 182 creative and deeply personal portraits and narratives. The five most frequent themes of portraits included "Residency is Difficult," "Hobbies," "Family," "Growing as a Doctor," and "Coping Mechanisms." Self-portrait photography and reflection gives insight into the journey of becoming a family medicine physician at a deeply personal and professional level. Further partnerships between residency programs and the arts should be explored to promote reflection.
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Affiliation(s)
- Christy L Tharenos
- Heartland Health Services, 2321 N Wisconsin Ave, Peoria, IL, 61603, USA.
| | - Amber M Hayden
- Cabarrus Family Medicine- Harrisburg, 4315 Physicians Blvd #101, Harrisburg, NC, 28075, USA
| | - Emily Cook
- Intermountain Healthcare, 975 E Chambers St, South Ogden, UT, 84403, USA
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Ilgen JS, Eva KW, de Bruin A, Cook DA, Regehr G. Comfort with uncertainty: reframing our conceptions of how clinicians navigate complex clinical situations. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:797-809. [PMID: 30390181 DOI: 10.1007/s10459-018-9859-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/17/2018] [Indexed: 05/23/2023]
Abstract
Learning to take safe and effective action in complex settings rife with uncertainty is essential for patient safety and quality care. Doing so is not easy for trainees, as they often consider certainty to be a necessary precursor for action and subsequently struggle in these settings. Understanding how skillful clinicians work comfortably when uncertain, therefore, offers an important opportunity to facilitate trainees' clinical reasoning development. This critical review aims to define and elaborate the concept of 'comfort with uncertainty' in clinical settings by juxtaposing a variety of frameworks and theories in ways that generate more deliberate ways of thinking about, and researching, this phenomenon. We used Google Scholar to identify theoretical concepts and findings relevant to the topics of 'uncertainty,' 'ambiguity,' 'comfort,' and 'confidence,' and then used preliminary findings to pursue parallel searches within the social cognition, cognition, sociology, sociocultural, philosophy of medicine, and medical education literatures. We treat uncertainty as representing the lived experience of individuals, reflecting the lack of confidence one feels that he/she has an incomplete mental representation of a particular problem. Comfort, in contrast, references confidence in one's capabilities to act (or not act) in a safe and effective manner given the situation. Clinicians' 'comfort with uncertainty' is informed by a variety of perceptual, emotional, and situational cues, and is enabled through a combination of self-monitoring and forward planning. Potential implications of using 'comfort with uncertainty' as a framework for educational and research programs are explored.
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Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine and Center for Leadership and Innovation in Medical Education, University of Washington School of Medicine, Seattle, WA, USA.
| | - Kevin W Eva
- Department of Medicine and Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
| | - Anique de Bruin
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - David A Cook
- Department of Medicine and Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Glenn Regehr
- Department of Surgery and Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
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Han PKJ, Babrow A, Hillen MA, Gulbrandsen P, Smets EM, Ofstad EH. Uncertainty in health care: Towards a more systematic program of research. PATIENT EDUCATION AND COUNSELING 2019; 102:1756-1766. [PMID: 31227333 DOI: 10.1016/j.pec.2019.06.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To promote a more systematic approach to research on uncertainty in health care, and to explore promising starting points and future directions for this research. METHODS We examine three fundamental aspects of medical uncertainty that a systematic research program should ideally address: its nature, effects, and communication. We summarize key insights from past empirical research and explore existing conceptual models that can help guide future research. RESULTS A diverse body of past research on medical uncertainty has produced valuable empirical insights and conceptual models that provide useful starting points for future empirical and theoretical work. However, these insights need to be more fully developed and integrated to answer remaining questions about what uncertainty is, how it affects people, and how and why it should be communicated. CONCLUSION Uncertainty in health care is an extremely important but incompletely understood phenomenon. Improving our understanding of the many important aspects of uncertainty in health care will require a more systematic program of research based upon shared, integrative conceptual models and active, collaborative engagement of the broader research community. PRACTICE IMPLICATIONS A more systematic approach to investigating uncertainty in health care can help elucidate how the clinical communication of uncertainty might be improved.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, USA; Tufts University School of Medicine, Boston, USA.
| | - Austin Babrow
- School of Communication Studies, Ohio University, Athens, USA
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Pål Gulbrandsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; HØKH Research Center, Akershus University Hospital, Lørenskog, Norway
| | - Ellen M Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Eirik H Ofstad
- Department of Medicine, Nordland Hospital Trust, Bodø, Norway; Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Harendza S. When strategy must follow structure…. GMS JOURNAL FOR MEDICAL EDUCATION 2019; 36:Doc47. [PMID: 31544147 PMCID: PMC6737255 DOI: 10.3205/zma001255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Sigrid Harendza
- Universitätsklinikum Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
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Liou KT, Jamorabo DS, Geha RM, Crawford CM, George P, Schiffman FJ. Foreign bodies: Is it feasible to develop tolerance for ambiguity among medical students through Equine-Facilitated learning? MEDICAL TEACHER 2019; 41:960-962. [PMID: 30857449 DOI: 10.1080/0142159x.2019.1578876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Intolerance of ambiguity among medical students is associated with negative attitudes towards psychosocially complex patients. In this paper, the authors evaluated the feasibility of a 3.5-hour workshop aimed at fostering tolerance for ambiguity in medical students through semi-structured interactions with horses that functioned as experiential surrogates for ambiguity. Among 26 first-year medical students who participated in the feasibility assessment, an overwhelming majority rated the workshop as academically valuable and recommended that it be offered again in the future. After feasibility was established, an additional group of 7 first-year medical students and 5 fourth-year students completed Budner's Tolerance of Ambiguity scale before and after the workshop to provide preliminary data on its effectiveness. The post-workshop mean scores on the Budner scale were lower than pre-workshop mean scores, suggesting that students developed greater tolerance for ambiguity following the workshop. This difference was statistically significant among the first-year students, but not among the fourth-year students. Our findings demonstrate that the equine-facilitated workshop is feasible and can potentially help medical students develop greater tolerance for ambiguity.
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Affiliation(s)
- Kevin T Liou
- Bendheim Integrative Medicine Center, Memorial Sloan Kettering Cancer Center , New York City , NY , USA
| | - Daniel S Jamorabo
- Department of Gastroenterology and Hepatology, New York-Presbyterian Brooklyn Methodist Hospital , Brooklyn , NY , USA
| | - Rabih M Geha
- Department of Internal Medicine, Fresno Center for Medical Education and Research, University of California-San Francisco , San Francisco , CA , USA
- Department of Medicine, San Francisco Veteran Affairs Medical Center , San Francisco , CA , USA
| | | | - Paul George
- Department of Medical Education, The Warren Alpert Medical School of Brown University , Providence , RI , USA
| | - Fred J Schiffman
- Department of Internal Medicine , The Warren Alpert Medical School of Brown University , Providence , RI , USA
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Leung J, Cloninger CR, Hong BA, Cloninger KM, Eley DS. Temperament and character profiles of medical students associated with tolerance of ambiguity and perfectionism. PeerJ 2019; 7:e7109. [PMID: 31223537 PMCID: PMC6571128 DOI: 10.7717/peerj.7109] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/09/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Certain personal attributes, such as perfectionism and tolerance of ambiguity, have been identified as influential in high achieving students. Medical students have been identified as high achievers and perfectionistic, and as such may be challenged by ambiguity. Medical students undertake a long and challenging degree. Personality has been shown to influence the well-being and coping and may equip some students to better cope with challenges. This paper examines the association between temperament and character personality profiles with measures of tolerance of ambiguity and with both adaptive and maladaptive constructs of perfectionism. METHODS A self-report questionnaire collected data on a sample of 808 Australian medical students in 2014 and 2015. Personality was measured using the Temperament and Character Inventory (TCIR-140) and classified traits as profiles using a latent class analysis. Two profiles were found. Profile 1 was characterized by low-average levels of Harm Avoidance, and high to very high levels of Persistence, Self-Directedness and Cooperativeness. Moderately-high levels of Harm Avoidance and high levels of Persistence, Self-Directedness and Cooperativeness characterized Profile 2. Moderation regression analyses were conducted to examine the association between the personality profiles with levels of Tolerance of Ambiguity (MSAT-II), Perfectionism-Concern over Mistakes and Perfectionism-High Standards (FMPS), considering demographic characteristics. RESULTS Students with Profile 1 were higher in levels of Tolerance of Ambiguity, and Perfectionism-High Standards, and lower levels of Perfectionism-Concern over Mistakes compared to Profile 2. These findings remained statistically significant after adjusting for age and gender. A significant personality by age interaction on Tolerance of Ambiguity was found. While higher levels of Tolerance of Ambiguity were associated with older age overall, it remained low across age for students with a personality Profile 2. CONCLUSIONS A particular combination of personality traits was identified to be associated with low Tolerance of Ambiguity and high levels of maladaptive Perfectionism. An intolerance of ambiguity and over concern about mistakes may be maladaptive and underlie vulnerability to stress and poor coping. The psychobiological model of personality provides insight into traits that are stable and those that can be self-regulated through education and training. The interaction between biological mechanisms and socio-cultural learning is relevant to a sample of medical students because it accounts for interaction of the biological or innate aspects of their personal development within an intense and competitive learning environment of medical school.
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Affiliation(s)
- Janni Leung
- The University of Queensland, Brisbane, Australia
| | - C. Robert Cloninger
- Department of Psychiatry, School of Medicine, Washington University, St. Louis, United States of America
| | - Barry A. Hong
- Department of Psychiatry, School of Medicine, Washington University, St. Louis, United States of America
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Mindfulness training for healthcare professionals and trainees: A meta-analysis of randomized controlled trials. J Psychosom Res 2019; 120:29-38. [PMID: 30929705 DOI: 10.1016/j.jpsychores.2019.03.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/02/2019] [Accepted: 03/04/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Healthcare professionals (HCPs) experience a wide range of physical and psychological symptoms that can affect quality of patient care. Previous meta-analyses exploring mindfulness-based interventions (MBIs) for HCPs have been limited by their narrow scope regarding intervention type, target population, and/or measures, and reliance on uncontrolled studies; therefore, a more comprehensive and methodologically rigorous examination is warranted. This meta-analysis quantified the effectiveness of MBIs on distress, well-being, physical health, and performance in HCPs and HCPs-in-training. METHOD RCTs examining the effect of meditation and MBIs on HCPs and HCPs-in-training were identified and reviewed. Two independent reviewers extracted data and assessed risk of bias. RESULTS Thirty-eight studies were included in the analyses (n = 2505; 75.88% female). Intervention had a significant moderate effect on anxiety (Hedge's g = 0.47), depression (Hedge's g = 0.41), psychological distress (Hedge's g = 0.46), and stress (Hedge's g = 0.52). Small to moderate effects were also found for burnout (Hedge's g = 0.26) and well-being at post-intervention (Hedge's g = 0.32). Effects were not significant for physical health and performance. Larger intervention effects on overall outcomes were found with HCPs (Hedge's g = 0.52), with Mindfulness-based Stress Reduction intervention (Hedge's g = 0.47), and inactive controls (Hedge's g = 0.36). CONCLUSIONS Results suggest mindfulness-based interventions are effective in reducing distress and improving well-being in HCPs and HCP-ITs. Subgroup analyses suggest the importance of exploring potential participants' needs prior to selecting the type of mindfulness intervention. Future studies should assess changes in mindfulness and include active controls.
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Tonelli MR, Upshur REG. A Philosophical Approach to Addressing Uncertainty in Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:507-511. [PMID: 30379664 DOI: 10.1097/acm.0000000000002512] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Conveying the uncertainty inherent in clinical practice has rightly become a focus of medical training. To date, much of the emphasis aims to encourage trainees to acknowledge and accept uncertainty. Intolerance of uncertainty is associated with medical student distress and a tendency in clinicians toward overtreatment. The authors argue that a deeper, philosophical understanding of the nature of uncertainty would allow students and clinicians to move beyond simple acceptance to explicating and mitigating uncertainty in practice.Uncertainty in clinical medicine can be categorized philosophically as moral, metaphysical, and epistemic uncertainty. Philosophers of medicine-in a way analogous to ethicists a half century ago-can be brought into medical education and medical practice to help students and physicians explore the epistemic and metaphysical roots of clinical uncertainty. Such an approach does not require medical students to master philosophy and should not involve adding new course work to an already-crowded medical curriculum. Rather, the goal is to provide students with the language and reasoning skills to recognize, evaluate, and mitigate uncertainty as it arises. The authors suggest ways in which philosophical concepts can be introduced in a practical fashion into a variety of currently existing educational formats. Bringing the philosophy of medicine into medical education promises not only to improve the training of physicians but, ultimately, to lead to more mindful clinical practice, to the benefit of physicians and patients alike.
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Affiliation(s)
- Mark R Tonelli
- M.R. Tonelli is professor of medicine and adjunct professor of bioethics and humanities, University of Washington, Seattle, Washington. R.E.G. Upshur is professor, Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Kemp S, Hu W, Bishop J, Forrest K, Hudson JN, Wilson I, Teodorczuk A, Rogers GD, Roberts C, Wearn A. Medical student wellbeing - a consensus statement from Australia and New Zealand. BMC MEDICAL EDUCATION 2019; 19:69. [PMID: 30832630 PMCID: PMC6399899 DOI: 10.1186/s12909-019-1505-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 02/22/2019] [Indexed: 05/20/2023]
Abstract
BACKGROUND Medical student wellbeing - a consensus statement from Australia and New Zealand outlines recommendations for optimising medical student wellbeing within medical schools in our region. Worldwide, medical schools have responsibilities to respond to concerns about student psychological, social and physical wellbeing, but guidance for medical schools is limited. To address this gap, this statement clarifies key concepts and issues related to wellbeing and provides recommendations for educational program design to promote both learning and student wellbeing. The recommendations focus on student selection; learning, teaching and assessment; learning environment; and staff development. Examples of educational initiatives from the evidence-base are provided, emphasising proactive and preventive approaches to student wellbeing. MAIN RECOMMENDATIONS The consensus statement provides specific recommendations for medical schools to consider at all stages of program design and implementation. These are: Design curricula that promote peer support and progressive levels of challenge to students. Employ strategies to promote positive outcomes from stress and to help others in need. Design assessment tasks to foster wellbeing as well as learning. Provide mental health promotion and suicide prevention initiatives. Provide physical health promotion initiatives. Ensure safe and health-promoting cultures for learning in on-campus and clinical settings. Train staff on student wellbeing and how to manage wellbeing concerns. CONCLUSION A broad integrated approach to improving student wellbeing within medical school programs is recommended. Medical schools should work cooperatively with student and trainee groups, and partner with clinical services and other training bodies to foster safe practices and cultures. Initiatives should aim to assist students to develop adaptive responses to stressful situations so that graduates are prepared for the realities of the workplace. Multi-institutional, longitudinal collaborative research in Australia and New Zealand is needed to close critical gaps in the evidence needed by medical schools in our region.
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Affiliation(s)
- Sandra Kemp
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia
| | - Wendy Hu
- School of Medicine, Western Sydney University, Penrith, New South Wales Australia
| | - Jo Bishop
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland Australia
| | - Kirsty Forrest
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland Australia
| | - Judith N. Hudson
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia
| | - Ian Wilson
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales Australia
| | - Andrew Teodorczuk
- School of Medicine, Griffith University, Gold Coast, Queensland Australia
| | - Gary D. Rogers
- School of Medicine, Griffith University, Gold Coast, Queensland Australia
| | - Chris Roberts
- Northern Clinical and Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales Australia
| | - Andy Wearn
- Medical Programme Directorate, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
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Benbassat J. Hypothesis: the hospital learning environment impedes students' acquisition of reflectivity and medical professionalism. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:185-194. [PMID: 29478106 DOI: 10.1007/s10459-018-9818-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 02/18/2018] [Indexed: 06/08/2023]
Abstract
Undergraduate clinical education follows the "bedside" tradition that exposes students to inpatients. However, the hospital learning environment has two main limitations. First, most inpatients require acute care, and students may complete their training without seeing patients with frequent non-emergent and chronic diseases that are managed in outpatient settings. Second, students rarely cope with diagnostic problems, because most inpatients are diagnosed in the community or the emergency room. These limitations have led some medical schools to offer longitudinal integrated clerkships in community settings instead of hospital block clerkship rotations. In this paper, I propose the hypothesis that the hospital learning environment has a third limitation: it causes students' distress and delays their development of reflectivity and medical professionalism. This hypothesis is supported by evidence that (a) the clinical learning environment, rather than students' personality traits, is the major driver of students' distress, and (b) the development of attributes, such as moral reasoning, empathy, emotional intelligence and tolerance of uncertainty that are included in the definitions of both reflectivity and medical professionalism, is arrested during undergraduate medical training. Future research may test the proposed hypothesis by comparing students' development of these attributes during clerkships in hospital wards with that during longitudinal clerkships in community settings.
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Affiliation(s)
- Jochanan Benbassat
- Department of Health Policy Research, Myers-JDC-Brookdale Institute, PO Box 3886, 91037, Jerusalem, Israel.
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Kim K, Lee YM. Understanding uncertainty in medicine: concepts and implications in medical education. KOREAN JOURNAL OF MEDICAL EDUCATION 2018; 30:181-188. [PMID: 30180505 PMCID: PMC6127608 DOI: 10.3946/kjme.2018.92] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/27/2018] [Accepted: 07/05/2018] [Indexed: 05/30/2023]
Abstract
In an era of high technology and low trust, acknowledging and coping with uncertainty is more crucial than ever. Medical uncertainty has been considered an innate feature of medicine and medical practice. An intolerance to uncertainty increases physicians' stress and the effects of burnout and may be a potential threat to patient safety. Understanding medical uncertainty and acquiring proper coping strategies has been regarded to be a core clinical competency for medical graduates and trainees. Integrating intuition and logic and creating a culture that acknowledges medical uncertainty could be suggested ways to teach medical uncertainty. In this article, the authors describe the concepts of medical uncertainty, its influences on physicians and on medical students toward medical decision making, the role of tolerance/intolerance to uncertainty, and proposed strategies to improve coping with medical uncertainty.
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Affiliation(s)
- Kangmoon Kim
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
| | - Young-Mee Lee
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
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Strout TD, Hillen M, Gutheil C, Anderson E, Hutchinson R, Ward H, Kay H, Mills GJ, Han PKJ. Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes. PATIENT EDUCATION AND COUNSELING 2018; 101:1518-1537. [PMID: 29655876 DOI: 10.1016/j.pec.2018.03.030] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 05/06/2023]
Abstract
BACKGROUND Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes. METHODS We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme. RESULTS Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being. CONCLUSIONS Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.
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Affiliation(s)
- Tania D Strout
- Department of Emergency Medicine, Maine Medical Center, Tufts University School of Medicine, 47 Bramhall Street, Portland, ME, 04102, USA.
| | - Marij Hillen
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Caitlin Gutheil
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Eric Anderson
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - Rebecca Hutchinson
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA; Hospice and Palliative Medicine, Maine Medical Center, Portland, ME, USA
| | - Hannah Ward
- University of Rochester, School of Medicine & Dentistry, Rochester, NY, USA
| | - Hannah Kay
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
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Li STT, Tancredi DJ, Schwartz A, Guillot A, Burke AE, Trimm RF, Guralnick S, Mahan JD, Gifford K. Pediatric Program Director Minimum Milestone Expectations Before Allowing Supervision of Others and Unsupervised Practice. Acad Pediatr 2018; 18:828-836. [PMID: 29704651 DOI: 10.1016/j.acap.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 04/19/2018] [Accepted: 04/21/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown. OBJECTIVE To determine pediatric program director (PD) minimum Milestone expectations for residents before being ready to supervise and before being ready to graduate. METHODS Mixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations were adjusted for program size, region, and clustering of Milestone expectations by program were calculated for before supervise and before graduate. Free-text questions were analyzed using thematic analysis. RESULTS The response rate was 56.8% (113 of 199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76 of 95) or ready to graduate (84%; 80 of 95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46; 95% confidence interval [CI], 2.21-2.71) and professionalization (2.37; 95% CI, 2.15-2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14; 95% CI, 2.83-3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions. CONCLUSIONS Most PDs have not established program minimum Milestones, but would vary such expectations according to competency.
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Affiliation(s)
- Su-Ting T Li
- Department of Pediatrics, University of California Davis, Sacramento, Calif.
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis, Sacramento, Calif; Center for Healthcare Policy and Research, University of California Davis, Sacramento, Calif
| | - Alan Schwartz
- Department of Medical Education, University of Illinois College of Medicine, Chicago, Ill; Department of Pediatrics, University of Illinois College of Medicine, Chicago, Ill
| | - Ann Guillot
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vt
| | - Ann E Burke
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - R Franklin Trimm
- Department of Pediatrics, University of South Alabama, Mobile, Ala
| | - Susan Guralnick
- Office of Academic Affairs, NYU Winthrop Hospital, Mineola, NY; Office of Graduate Medical Education and Department of Pediatrics, University of California Davis, Sacramento, Calif
| | - John D Mahan
- Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio
| | - Kimberly Gifford
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH
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Simpkin AL, Khan A, West DC, Garcia BM, Sectish TC, Spector ND, Landrigan CP. Stress From Uncertainty and Resilience Among Depressed and Burned Out Residents: A Cross-Sectional Study. Acad Pediatr 2018. [PMID: 29524616 DOI: 10.1016/j.acap.2018.03.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Depression and burnout are highly prevalent among residents, but little is known about modifiable personality variables, such as resilience and stress from uncertainty, that may predispose to these conditions. Residents are routinely faced with uncertainty when making medical decisions. OBJECTIVE To determine how stress from uncertainty is related to resilience among pediatric residents and whether these attributes are associated with depression and burnout. METHODS We surveyed 86 residents in pediatric residency programs from 4 urban freestanding children's hospitals in North America in 2015. Stress from uncertainty was measured with the use of the Physicians' Reaction to Uncertainty Scale, resilience with the use of the 14-item Resilience Scale, depression with the use of the Harvard National Depression Screening Scale; and burnout with the use of single-item measures of emotional exhaustion and depersonalization from the Maslach Burnout Inventory. RESULTS Fifty out of 86 residents responded to the survey (58.1%). Higher levels of stress from uncertainty correlated with lower resilience (r = -0.60; P < .001). Five residents (10%) met depression criteria and 15 residents (31%) met burnout criteria. Depressed residents had higher mean levels of stress due to uncertainty (51.6 ± 9.1 vs 38.7 ± 6.7; P < .001) and lower mean levels of resilience (56.6 ± 10.7 vs 85.4 ± 8.0; P < .001) compared with residents who were not depressed. Burned out residents also had higher mean levels of stress due to uncertainty (44.0 ± 8.5 vs 38.3 ± 7.1; P = .02) and lower mean levels of resilience (76.7 ± 14.8 vs 85.0 ± 9.77; P = .02) compared with residents who were not burned out. CONCLUSIONS We found high levels of stress from uncertainty, and low levels of resilience were strongly correlated with depression and burnout. Efforts to enhance tolerance of uncertainty and resilience among residents may provide opportunities to mitigate resident depression and burnout.
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Affiliation(s)
- Arabella L Simpkin
- Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Department of Pharmacology, University of Oxford, Oxford, UK.
| | - Alisa Khan
- Harvard Medical School, Boston, Mass; Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Daniel C West
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, Calif
| | - Briana M Garcia
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Theodore C Sectish
- Harvard Medical School, Boston, Mass; Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Nancy D Spector
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pa
| | - Christopher P Landrigan
- Harvard Medical School, Boston, Mass; Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
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Gaufberg E, Dunham L, Krupat E, Stansfield B, Christianson C, Skochelak S. Do Gold Humanism Honor Society Inductees Differ From Their Peers in Empathy, Patient-Centeredness, Tolerance of Ambiguity, Coping Style, and Perception of the Learning Environment? TEACHING AND LEARNING IN MEDICINE 2018; 30:284-293. [PMID: 29364745 DOI: 10.1080/10401334.2017.1419873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Construct: Induction into the Gold Humanism Honor Society (GHHS) during medical school is recognized as an indicator of humanistic orientation and behavior. Various attitudes and interpersonal orientations including empathy and patient-centeredness have been posited to translate into behaviors constituting humanistic care. BACKGROUND To our knowledge there has never been a longitudinal, multi-institutional empirical study of the attitudinal and interpersonal orientations correlated with GHHS membership status. APPROACH We used the American Medical Association Learning Environment Study (LES) data set to explore attitudinal correlates associated with students whose behaviors are recognized by their peers as being exceptionally humanistic. Specifically, we examined whether empathy, patient-centeredness, tolerance of ambiguity, coping style, and perceptions of the learning environment are associated with GHHS membership status. We further considered to what extent GHHS members arrive in medical school with these attitudinal correlates and to what extent they change and evolve differentially among GHHS members compared to their non-GHHS peers. Between 2011 and 2015, 585 students from 13 North American medical schools with GHHS chapters participated in the LES, a longitudinal cohort study using a battery of validated psychometric measures including the Jefferson Scale of Empathy, Patient-Practitioner Orientation Scale and Tolerance of Ambiguity Questionnaire. In the final survey administration, students self-identified as GHHS inductees or not (non-GHHS). T tests, effect sizes, and longitudinal generalized mixed-effects models examined the differences between GHHS and non-GHHS students. RESULTS Students inducted into GHHS scored significantly higher on average over 4 years than non-GHHS inductees on clinical empathy, patient-centered beliefs, and tolerance of ambiguity. GHHS students reported higher levels of empathy and patient-centeredness at medical school matriculation. This difference persists in the 4th year of medical school and when controlling for time, race, gender, and school. CONCLUSIONS GHHS inductees enter medical school with different attitudes and beliefs than their non-GHHS classmates. Although humanistic attitudes and beliefs vary over time during students' 4 years, the gap between the two groups remains constant. Medical schools may want to consider selecting for specific humanistic traits during admissions as well as fostering the development of humanism through curricular interventions.
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Affiliation(s)
- Elizabeth Gaufberg
- a Departments of Medicine and Psychiatry , Harvard Medical School/The Cambridge Health Alliance , Cambridge , Massachusetts , USA
- f Arnold P. Gold Foundation Research Institute , Cambridge , Massachusetts , USA
| | - Lisette Dunham
- b Department of Medical Education , American Medical Association , Chicago , Illinois , USA
| | - Edward Krupat
- c Center for Evaluation, Harvard Medical School , Boston , Massachusetts , USA
| | - Brent Stansfield
- d Graduate Medical Education, Wayne State University , Detroit , Michigan , USA
| | - Charles Christianson
- e School of Medicine and Health Sciences, University of North Dakota, Grand Forks , North Dakota , USA
| | - Susan Skochelak
- b Department of Medical Education , American Medical Association , Chicago , Illinois , USA
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Mangione S, Chakraborti C, Staltari G, Harrison R, Tunkel AR, Liou KT, Cerceo E, Voeller M, Bedwell WL, Fletcher K, Kahn MJ. Medical Students' Exposure to the Humanities Correlates with Positive Personal Qualities and Reduced Burnout: A Multi-Institutional U.S. Survey. J Gen Intern Med 2018; 33:628-634. [PMID: 29380213 PMCID: PMC5910341 DOI: 10.1007/s11606-017-4275-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 10/27/2017] [Accepted: 12/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Literature, music, theater, and visual arts play an uncertain and limited role in medical education. One of the arguments often advanced in favor of teaching the humanities refers to their capacity to foster traits that not only improve practice, but might also reduce physician burnout-an increasing scourge in today's medicine. Yet, research remains limited. OBJECTIVE To test the hypothesis that medical students with higher exposure to the humanities would report higher levels of positive physician qualities (e.g., wisdom, empathy, self-efficacy, emotional appraisal, spatial skills), while reporting lower levels of negative qualities that are detrimental to physician well-being (e.g., intolerance of ambiguity, physical fatigue, emotional exhaustion, and cognitive weariness). DESIGN An online survey. PARTICIPANTS All students enrolled at five U.S. medical schools during the 2014-2015 academic year were invited by email to take part in our online survey. MAIN MEASURES Students reported their exposure to the humanities (e.g., music, literature, theater, visual arts) and completed rating scales measuring selected personal qualities. KEY RESULTS In all, 739/3107 medical students completed the survey (23.8%). Regression analyses revealed that exposure to the humanities was significantly correlated with positive personal qualities, including empathy (p < 0.001), tolerance for ambiguity (p < 0.001), wisdom (p < 0.001), emotional appraisal (p = 0.01), self-efficacy (p = 0.02), and spatial skills (p = 0.02), while it was significantly and inversely correlated with some components of burnout (p = 0.01). Thus, all hypotheses were statistically significant, with effect sizes ranging from 0.2 to 0.59. CONCLUSIONS This study confirms the association between exposure to the humanities and both a higher level of students' positive qualities and a lower level of adverse traits. These findings may carry implications for medical school recruitment and curriculum design. "[Science and humanities are] twin berries on one stem, grievous damage has been done to both in regarding [them]... in any other light than complemental." (William Osler, Br Med J. 1919;2:1-7).
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Affiliation(s)
- Salvatore Mangione
- Sidney Kimmel Medical College of Thomas Jefferson University, 1001 Locust Street – Suite 309C, Philadelphia, PA 19107 USA
| | - Chayan Chakraborti
- Tulane University School of Medicine, 1430 Tulane Ave, SL-16, New Orleans, LA 70112 USA
| | - Giuseppe Staltari
- Department of Otolaryngology and Head and Neck Surgery, University of Pittsburgh Medical Center, 203 Lothrop Street, Suite 519, Pittsburgh, PA 15213 USA
| | - Rebecca Harrison
- OHSU School of Medicine, 3181 SW Sam Jackson Park Rd, P ortland, OR 97239 USA
| | - Allan R. Tunkel
- The Warren Alpert Medical School of Brown University, 222 Richmond Street, Room G-M143, Providence, RI 02912 USA
| | - Kevin T. Liou
- Weill Cornell Internal Medicine Associates, 505 East 70th Street, Suite 4, New York, NY 10021 USA
| | - Elizabeth Cerceo
- Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ 08103 USA
| | - Megan Voeller
- Office of Student Life & Engagement, Thomas Jefferson University, 1020 Locust Street, Suite 163, Philadelphia, PA 19107 USA
| | | | - Keaton Fletcher
- Department of Psychology, University of South Florida, 4202 E Fowler Ave, Tampa, FL 33620 USA
| | - Marc J. Kahn
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave., #8010, New Orleans, LA 70112 USA
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White G, Williams S. The certainty of uncertainty: can we teach a constructive response? MEDICAL EDUCATION 2017; 51:1200-1202. [PMID: 29124799 DOI: 10.1111/medu.13466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Cooke G, Tapley A, Holliday E, Morgan S, Henderson K, Ball J, van Driel M, Spike N, Kerr R, Magin P. Responses to clinical uncertainty in Australian general practice trainees: a cross-sectional analysis. MEDICAL EDUCATION 2017; 51:1277-1288. [PMID: 29124801 DOI: 10.1111/medu.13408] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/07/2017] [Accepted: 07/04/2017] [Indexed: 06/07/2023]
Abstract
CONTEXT Tolerance for ambiguity is essential for optimal learning and professional competence. General practice trainees must be, or must learn to be, adept at managing clinical uncertainty. However, few studies have examined associations of intolerance of uncertainty in this group. OBJECTIVES The aim of this study was to establish levels of tolerance of uncertainty in Australian general practice trainees and associations of uncertainty with demographic, educational and training practice factors. METHODS A cross-sectional analysis was performed on the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing multi-site cohort study. Scores on three of the four independent subscales of the Physicians' Reaction to Uncertainty (PRU) instrument were analysed as outcome variables in linear regression models with trainee and practice factors as independent variables. RESULTS A total of 594 trainees contributed data on a total of 1209 occasions. Trainees in earlier training terms had higher scores for 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose diagnosis/treatment uncertainty to patients'. Beyond this, findings suggest two distinct sets of associations regarding reaction to uncertainty. Firstly, affective aspects of uncertainty (the 'Anxiety' and 'Concern' subscales) were associated with female gender, less experience in hospital prior to commencing general practice training, and graduation overseas. Secondly, a maladaptive response to uncertainty (the 'Reluctance to disclose' subscale) was associated with urban practice, health qualifications prior to studying medicine, practice in an area of higher socio-economic status, and being Australian-trained. CONCLUSIONS This study has established levels of three measures of trainees' responses to uncertainty and associations with these responses. The current findings suggest differing 'phenotypes' of trainees with high 'affective' responses to uncertainty and those reluctant to disclose uncertainty to patients. More research is needed to examine the relationship between clinical uncertainty and clinical outcomes, temporal changes in tolerance for uncertainty, and strategies that might assist physicians in developing adaptive responses to clinical uncertainty.
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Affiliation(s)
- Georga Cooke
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | | | - Elizabeth Holliday
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Simon Morgan
- GP Synergy Ltd, Sydney, New South Wales, Australia
| | | | - Jean Ball
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Mieke van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Neil Spike
- Eastern Victoria GP Training, Hawthorn, Victoria, Australia
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Rohan Kerr
- General Practice Training Tasmania, Hobart, Tasmania, Australia
| | - Parker Magin
- GP Synergy Ltd, Sydney, New South Wales, Australia
- School of Medicine and Public Health, Faculty of Health and Medicine, Newcastle University, Newcastle, New South Wales, Australia
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Bentwich ME, Gilbey P. More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy. BMC MEDICAL EDUCATION 2017; 17:200. [PMID: 29126410 PMCID: PMC5681760 DOI: 10.1186/s12909-017-1028-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 10/31/2017] [Indexed: 05/22/2023]
Abstract
BACKGROUND Comfort with ambiguity, mostly associated with the acceptance of multiple meanings, is a core characteristic of successful clinicians. Yet past studies indicate that medical students and junior physicians feel uncomfortable with ambiguity. Visual Thinking Strategies (VTS) is a pedagogic approach involving discussions of art works and deciphering the different possible meanings entailed in them. However, the contribution of art to the possible enhancement of the tolerance for ambiguity among medical students has not yet been adequately investigated. We aimed to offer a novel perspective on the effect of art, as it is experienced through VTS, on medical students' tolerance of ambiguity and its possible relation to empathy. METHODS Quantitative method utilizing a short survey administered after an interactive VTS session conducted within mandatory medical humanities course for first-year medical students. The intervention consisted of a 90-min session in the form of a combined lecture and interactive discussions about art images. The VTS session and survey were filled by 67 students in two consecutive rounds of first-year students. RESULTS 67% of the respondents thought that the intervention contributed to their acceptance of multiple possible meanings, 52% thought their visual observation ability was enhanced and 34% thought that their ability to feel the sufferings of other was being enhanced. Statistically significant moderate-to-high correlations were found between the contribution to ambiguity tolerance and contribution to empathy (0.528-0.744; p ≤ 0.01). CONCLUSIONS Art may contribute especially to the development of medical students' tolerance of ambiguity, also related to the enhancement of empathy. The potential contribution of visual art works used in VTS to the enhancement of tolerance for ambiguity and empathy is explained based on relevant literature regarding the embeddedness of ambiguity within art works, coupled with reference to John Dewey's theory of learning. Given the situational nature of the tolerance for ambiguity in this context, VTS provides a path for enhancing ambiguity tolerance that is less conditioned by character traits. Moreover, the modest form of VTS we utilized, not requesting a significant alteration in the pre-clinical curricula, suggests that enhancing the tolerance of ambiguity and empathy among medical students may be particularly feasible.
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Affiliation(s)
- Miriam Ethel Bentwich
- Faculty of Medicine, Bar-Ilan University, Safed Campus, P.O. Box 1589, Ramat Gan, Israel
| | - Peter Gilbey
- Faculty of Medicine, Bar-Ilan University, Safed Campus, P.O. Box 1589, Ramat Gan, Israel
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McMahon MA, Dluhy NM. Ambiguity Within Nursing Practice: An Evolutionary Concept Analysis. Res Theory Nurs Pract 2017; 31:56-74. [DOI: 10.1891/1541-6577.31.1.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose:To analyze the concept of ambiguity in a nursing context.Background:Ambiguity is inherent within nursing practice. As health care becomes increasingly complex, nurses must continue to successfully deal with greater amounts of clinical ambiguity. Although ambiguity is discussed in nursing, minimal concept refinement exists to capture the contextual intricacies from a nursing lens. Nurse perception of an ambiguous clinical event, in combination with nurse tolerance level for ambiguity, can impact nurse response. Yet, little is known about what constitutes ambiguity within nursing practice (AWNP).Method:Rodgers evolutionary method was used to explore AWNP, with emphasis on nurse thinking during ambiguous clinical situations. Literature searches across multiple databases yielded 38 articles for analysis.Results:Attributesof AWNP include (a) variations in cues/available information, (b) multiple interpretations, (c) novel/nonroutine presentations, and (d) unpredictable.Antecedentsinclude (a) a context-specific, clinical situation with ambiguous features needing evaluation and (b) an individual to sense a knowledge gap or perceive ambiguity.Consequencesinclude ranges of (a) emotional, (b) behavioral, and (c) cognitive clinician responses.Conclusion:Preliminary findings support AWNP as a distinct concept in which ambiguity perceived by the nurse likely affects judgment, decision making, and clinical interventions. AWNP is a clinically relevant concept requiring continued development.
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Hancock J, Hammond JA, Roberts M, Mattick K. Comparing Tolerance of Ambiguity in Veterinary and Medical Students. JOURNAL OF VETERINARY MEDICAL EDUCATION 2017; 44:523-530. [PMID: 28876986 DOI: 10.3138/jvme.0916-150r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Current guidelines suggest that educators in both medical and veterinary professions should do more to ensure that students can tolerate ambiguity. Designing curricula to achieve this requires the ability to measure and understand differences in ambiguity tolerance among and within professional groups. Although scales have been developed to measure tolerance of ambiguity in both medical and veterinary professions, no comparative studies have been reported. We compared the tolerance of ambiguity of medical and veterinary students, hypothesizing that veterinary students would have higher tolerance of ambiguity, given the greater patient diversity and less well-established evidence base underpinning practice. We conducted a secondary analysis of questionnaire data from first- to fourth-year medical and veterinary students. Tolerance of ambiguity scores were calculated and compared using the TAMSAD scale (29 items validated for the medical student population), the TAVS scale (27 items validated for the veterinary student population), and a scale comprising the 22 items common to both scales. Using the TAMSAD and TAVS scales, medical students had a significantly higher mean tolerance of ambiguity score than veterinary students (56.1 vs. 54.1, p<.001 and 60.4 vs. 58.5, p=.002, respectively) but no difference was seen when only the 22 shared items were compared (56.1 vs. 57.2, p=.513). The results do not support our hypothesis and highlight that different findings can result when different tools are used. Medical students may have slightly higher tolerance of ambiguity than veterinary students, although this depends on the scale used.
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Hammond JA, Hancock J, Martin MS, Jamieson S, Mellor DJ. Development of a New Scale to Measure Ambiguity Tolerance in Veterinary Students. JOURNAL OF VETERINARY MEDICAL EDUCATION 2017; 44:38-49. [PMID: 28206843 DOI: 10.3138/jvme.0216-040r] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The ability to cope with ambiguity and feelings of uncertainty is an essential part of professional practice. Research with physicians has identified that intolerance of ambiguity or uncertainty is linked to stress, and some authors have hypothesized that there could be an association between intolerance of ambiguity and burnout. We describe the adaptation of the TAMSAD (Tolerance of Ambiguity in Medical Students and Doctors) scale for use with veterinary students. Exploratory factor analysis supports a uni-dimensional structure for the Ambiguity tolerance construct. Although internal reliability of the 29-item TAMSAD scale is reasonable (α=.50), an alternative 27-item scale (drawn from the original 41 items used to develop TAMSAD) shows higher internal reliability for veterinary students (α=.67). We conclude that there is good evidence to support the validity of this latter TAVS (Tolerance of Ambiguity in Veterinary Students) scale to study ambiguity tolerance in veterinary students.
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Iannello P, Mottini A, Tirelli S, Riva S, Antonietti A. Ambiguity and uncertainty tolerance, need for cognition, and their association with stress. A study among Italian practicing physicians. MEDICAL EDUCATION ONLINE 2017; 22:1270009. [PMID: 28178917 PMCID: PMC5328324 DOI: 10.1080/10872981.2016.1270009] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
UNLABELLED Medical practice is inherently ambiguous and uncertain. The physicians' ability to tolerate ambiguity and uncertainty has been proved to have a great impact on clinical practice. The primary aim of the present study was to test the hypothesis that higher degree of physicians' ambiguity and uncertainty intolerance and higher need for cognitive closure will predict higher work stress. Two hundred and twelve physicians (mean age = 42.94 years; SD = 10.72) from different medical specialties with different levels of expertise were administered a set of questionnaires measuring perceived levels of work-related stress, individual ability to tolerate ambiguity, stress deriving from uncertainty, and personal need for cognitive closure. A linear regression analysis was performed to examine which variables predict the perceived level of stress. The regression model was statistically significant [R2 = .32; F(10,206) = 8.78, p ≤ .001], thus showing that, after controlling for gender and medical specialty, ambiguity and uncertainty tolerance, decisiveness (a dimension included in need for closure), and the years of practice were significant predictors of perceived work-related stress. Findings from the present study have some implications for medical education. Given the great impact that the individual ability to tolerate ambiguity and uncertainty has on the physicians' level of perceived work-related stress, it would be worth paying particular attention to such a skill in medical education settings. It would be crucial to introduce or to empower educational tools and strategies that could increase medical students' ability to tolerate ambiguity and uncertainty. ABBREVIATIONS JSQ: Job stress questionnaire; NFCS: Need for cognitive closure scale; PRU: Physicians' reactions to uncertainty; TFA: Tolerance for ambiguity.
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Affiliation(s)
- Paola Iannello
- Department of Psychology – Research Unit on Decision-making Processes in Emergency Medicine, Catholic University of the Sacred Heart, Milan, Italy
- CONTACT Paola Iannello Department of Psychology, Catholic University of the Sacred Heart, Largo Gemelli, 1, Milan20123, Italy
| | - Anna Mottini
- Department of Psychology – Research Unit on Decision-making Processes in Emergency Medicine, Catholic University of the Sacred Heart, Milan, Italy
| | - Simone Tirelli
- Department of Psychology – Research Unit on Decision-making Processes in Emergency Medicine, Catholic University of the Sacred Heart, Milan, Italy
| | - Silvia Riva
- University of Milan, Department of Health Sciences, Milan, Italy
| | - Alessandro Antonietti
- Department of Psychology – Research Unit on Decision-making Processes in Emergency Medicine, Catholic University of the Sacred Heart, Milan, Italy
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Waddimba AC, Scribani M, Krupa N, May JJ, Jenkins P. Frequency of satisfaction and dissatisfaction with practice among rural-based, group-employed physicians and non-physician practitioners. BMC Health Serv Res 2016; 16:613. [PMID: 27770772 PMCID: PMC5075400 DOI: 10.1186/s12913-016-1777-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 09/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Widespread dissatisfaction among United States (U.S.) clinicians could endanger ongoing reforms. Practitioners in rural/underserved areas withstand stressors that are unique to or accentuated in those settings. Medical professionals employed by integrating delivery systems are often distressed by the cacophony of organizational change(s) that such consolidation portends. We investigated the factors associated with dis/satisfaction with rural practice among doctors/non-physician practitioners employed by an integrated healthcare delivery network serving 9 counties of upstate New York, during a time of organizational transition. METHODS We linked administrative data about practice units with cross-sectional data from a self-administered multi-dimensional questionnaire that contained practitioner demographics plus valid scales assessing autonomy/relatedness needs, risk aversion, tolerance for uncertainty/ambiguity, meaningfulness of patient care, and workload. We targeted medical professionals on the institutional payroll for inclusion. We excluded those who retired, resigned or were fired during the study launch, plus members of the advisory board and research team. Fixed-effects beta regressions were performed to test univariate associations between each factor and the percent of time a provider was dis/satisfied. Factors that manifested significant fixed effects were entered into multivariate, inflated beta regression models of the proportion of time that practitioners were dis/satisfied, incorporating clustering by practice unit as a random effect. RESULTS Of the 473 eligible participants. 308 (65.1 %) completed the questionnaire. 59.1 % of respondents were doctoral-level; 40.9 % mid-level practitioners. Practitioners with heavier workloads and/or greater uncertainty intolerance were less likely to enjoy top-quintile satisfaction; those deriving greater meaning from practice were more likely. Higher meaningfulness and gratified relational needs increased one's likelihood of being in the lowest quintile of dissatisfaction; heavier workload and greater intolerance of uncertainty reduced that likelihood. Practitioner demographics and most practice unit characteristics did not manifest any independent effect. CONCLUSIONS Mutable factors, such as workload, work meaningfulness, relational needs, uncertainty/ambiguity tolerance, and risk-taking attitudes displayed the strongest association with practitioner satisfaction/dissatisfaction, independent of demographics and practice unit characteristics. Organizational efforts should be dedicated to a redesign of group-employment models, including more equitable division of clinical labor, building supportive peer networks, and uncertainty/risk tolerance coaching, to improve the quality of work life among rural practitioners.
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Affiliation(s)
- Anthony C Waddimba
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA. .,Columbia University College of Physicians and Surgeons, 630 West 168th St, New York, NY, 10032, USA.
| | - Melissa Scribani
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA
| | - Nicole Krupa
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA
| | - John J May
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA.,Columbia University Mailman School of Public Health, 722 West 168th St, New York, NY, 10032, USA
| | - Paul Jenkins
- Bassett Healthcare Network, Research Institute, 1 Atwell Road, Cooperstown, NY, 13326, USA
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Waddimba AC, Scribani M, Hasbrouck MA, Krupa N, Jenkins P, May JJ. Resilience among Employed Physicians and Mid-Level Practitioners in Upstate New York. Health Serv Res 2016; 51:1706-34. [PMID: 27620116 DOI: 10.1111/1475-6773.12499] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To investigate the factors associated with resilience among medical professionals. DATA SOURCES/STUDY SETTING Administrative information from a rural health care network (1 academic medical center, 6 hospitals, 31 clinics, and 20 school health centers) was triangulated with self-report data from 308 respondents (response rate = 65.1 percent) to a 9/2013-1/2014 survey among practitioners serving a nine-county 5,600-square-mile area. STUDY DESIGN A cross-sectional questionnaire survey comprising valid measures of resilience, practice meaningfulness, satisfaction, and risk/uncertainty intolerance, nested within a prospective, community-based project. DATA COLLECTION/EXTRACTION METHODS The sampling frame included practitioners on institutional payroll, excluding voluntary/involuntary attritions and advisory board/research team members. In multivariable mixed-effects models, we regressed full-range and high-/low-resilience scores on demographics, professional satisfaction, workplace needs, risk/uncertainty intolerance, and service unit characteristics. PRINCIPAL FINDINGS Relational needs, uncertainty intolerance, satisfaction ≥75 percent of the time, number of practitioners on a unit, and workload were significantly associated with resilience. Higher scores were most strongly associated with uncertainty tolerance, satisfaction, and practitioner numbers. Practitioner/unit demographics were mostly nonsignificant. CONCLUSIONS More resilient practitioners experienced frequent satisfaction, relational needs gratification, better uncertainty tolerance, lighter workloads, and practiced on units with more colleagues. Further studies should investigate well-being interventions based on these mutable factors.
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Affiliation(s)
- Anthony C Waddimba
- Health Services Research Scientist, Bassett Healthcare Network, Research Institute, Cooperstown, NY. .,Assistant Professor of Pediatrics, Columbia University College of Physicians & Surgeons, Cooperstown, NY.
| | - Melissa Scribani
- Biostatistics and Computing Center, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - Melinda A Hasbrouck
- Health Services Research Scientist, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - Nicole Krupa
- Biostatistics and Computing Center, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - Paul Jenkins
- Biostatistics and Computing Center, Bassett Healthcare Network, Research Institute, Cooperstown, NY
| | - John J May
- Health Services Research Scientist, Bassett Healthcare Network, Research Institute, Cooperstown, NY.,Department of Epidemiology, Columbia University Mailman School of Public Health, Cooperstown, New York
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Han PK, Dieckmann NF, Holt C, Gutheil C, Peters E. Factors Affecting Physicians' Intentions to Communicate Personalized Prognostic Information to Cancer Patients at the End of Life: An Experimental Vignette Study. Med Decis Making 2016; 36:703-13. [PMID: 26985015 PMCID: PMC4930679 DOI: 10.1177/0272989x16638321] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/21/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE To explore the effects of personalized prognostic information on physicians' intentions to communicate prognosis to cancer patients at the end of life, and to identify factors that moderate these effects. METHODS A factorial experiment was conducted in which 93 family medicine physicians were presented with a hypothetical vignette depicting an end-stage gastric cancer patient seeking prognostic information. Physicians' intentions to communicate prognosis were assessed before and after provision of personalized prognostic information, while emotional distress of the patient and ambiguity (imprecision) of the prognostic estimate were varied between subjects. General linear models were used to test the effects of personalized prognostic information, patient distress, and ambiguity on prognostic communication intentions, and potential moderating effects of 1) perceived patient distress, 2) perceived credibility of prognostic models, 3) physician numeracy (objective and subjective), and 4) physician aversion to risk and ambiguity. RESULTS Provision of personalized prognostic information increased prognostic communication intentions (P < 0.001, η(2) = 0.38), although experimentally manipulated patient distress and prognostic ambiguity had no effects. Greater change in communication intentions was positively associated with higher perceived credibility of prognostic models (P = 0.007, η(2) = 0.10), higher objective numeracy (P = 0.01, η(2) = 0.09), female sex (P = 0.01, η(2) = 0.08), and lower perceived patient distress (P = 0.02, η(2) = 0.07). Intentions to communicate available personalized prognostic information were positively associated with higher perceived credibility of prognostic models (P = 0.02, η(2) = 0.09), higher subjective numeracy (P = 0.02, η(2) = 0.08), and lower ambiguity aversion (P = 0.06, η(2) = 0.04). CONCLUSIONS Provision of personalized prognostic information increases physicians' prognostic communication intentions to a hypothetical end-stage cancer patient, and situational and physician characteristics moderate this effect. More research is needed to confirm these findings and elucidate the determinants of prognostic communication at the end of life.
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Affiliation(s)
- Paul K.J. Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME
- Tufts University Clinical and Translational Sciences Institute, Boston, MA
| | - Nathan F. Dieckmann
- School of Nursing & School of Medicine, Oregon Health & Science University, Portland, OR
- Decision Research, Eugene, OR
| | - Christina Holt
- Department of Family Medicine, Maine Medical Center, Portland, ME
| | - Caitlin Gutheil
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME
| | - Ellen Peters
- Department of Psychology, Ohio State University, Columbus, OH
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Domen RE. The Ethics of Ambiguity: Rethinking the Role and Importance of Uncertainty in Medical Education and Practice. Acad Pathol 2016; 3:2374289516654712. [PMID: 28725771 PMCID: PMC5497921 DOI: 10.1177/2374289516654712] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/16/2016] [Accepted: 05/18/2016] [Indexed: 12/21/2022] Open
Abstract
Understanding and embracing uncertainty are critical for effective teacher–learner relationships as well as for shared decision-making in the physician–patient relationship. However, ambiguity has not been given serious consideration in either the undergraduate or graduate medical curricula or in the role it plays in patient-centered care. In this article, the author examines the ethics of ambiguity and argues for a pedagogy that includes education in the importance of, and tolerance of, ambiguity that is inherent in medical education and practice. Common threads running through the ethics of ambiguity are the virtue of respect, and the development of a culture of respect is required for the successful understanding and implementation of a pedagogy of ambiguity.
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Affiliation(s)
- Ronald E Domen
- Division of Clinical Pathology (Laboratory Medicine), Department of Pathology, Penn State Hershey Medical Center and College of Medicine, Hershey, PA, USA
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