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Brun C, Zerhouni O, Akinyemi A, Houtin L, Monvoisin R, Pinsault N. Impact of uncertainty intolerance on clinical reasoning: A scoping review of the 21st-century literature. J Eval Clin Pract 2023; 29:539-553. [PMID: 36071694 DOI: 10.1111/jep.13756] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/11/2022] [Accepted: 08/16/2022] [Indexed: 12/29/2022]
Abstract
UNLABELLED RATIONALE, AIMS AND OBJECTIVES: Clinical reasoning is currently extensively studied to find out how to make proper diagnoses. Literature indicates that intolerance of uncertainty (IU) may have a strong negative impact on clinical reasoning. We summarize the various consequences of IU on clinical reasoning. METHODS A scoping review was conducted using relevant keywords to scientific databases (i.e., Google Scholar, Medline, PsycINFO and PBSC) from September to November 2021. Complementary research included relevant articles and articles retrieved through Google Scholar's alert system. We included articles about healthcare professionals as defined by the French Public Health Code (As defined here: https://www.vie-publique.fr/fiches/37855-categories-de-professionnels-de-sante-code-se-la-sante-publique), and articles reporting on the impact of IU or uncertainty management on clinical reasoning. RESULTS We retrieved 1853 articles, of which 8 were kept for final analysis considering our inclusion criteria. Two behaviour categories were affected by uncertainty intolerance: investigative and prescriptive behaviours. Regarding the investigation process, mismanagement of uncertainty appeared to lead to reasoning bias, potentially resulting in diagnostic errors. IU was associated with withholding information, more referrals to peers and less use of new medical interventions. Regarding prescription behaviours, IU among health professionals could lead to overprescribing unnecessary or dangerous tests. IU was also associated with more antibiotic prescriptions for conditions where antibiotics are to be used carefully. CONCLUSION Few studies have yet addressed the impact of IU on clinical reasoning. IU's influence is primarily observed on investigative and prescribing behaviours. More studies are needed to fully understand the impact of IU on clinical reasoning itself, and not only on practical consequences.
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Affiliation(s)
- Clémence Brun
- Université Grenoble Alpes, TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Domaine de la Merci, La Tronche, France
| | - Oulmann Zerhouni
- Laboratoire Parisien de Psychologie Sociale, EA 4386 (équipe PS2C), Nanterre, France
| | - Alexis Akinyemi
- Laboratoire Parisien de Psychologie Sociale, EA 4386 (équipe PS2C), Nanterre, France
| | - Laurène Houtin
- Laboratoire Parisien de Psychologie Sociale, EA 4386 (équipe PS2C), Nanterre, France
| | - Richard Monvoisin
- Université Grenoble Alpes, TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Domaine de la Merci, La Tronche, France
| | - Nicolas Pinsault
- Université Grenoble Alpes, TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Domaine de la Merci, La Tronche, France
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Lohse S. Mapping uncertainty in precision medicine: A systematic scoping review. J Eval Clin Pract 2023; 29:554-564. [PMID: 36372904 DOI: 10.1111/jep.13789] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/14/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Abstract
RATIONALE Although precision medicine is seen by many as one of the most promising advances in the field of medicine, it has also raised critical questions at various levels. Many of these concerns revolve around an observation described by Kimmelman and Tannock as the 'paradox of precision medicine': somewhat surprisingly, uncertainty seems to be a key characteristic of precision medicine in practice. AIMS AND OBJECTIVE To better understand this concept and the underlying issues, a scoping review was undertaken to search for factors stated in the literature as contributing to or being aspects of uncertainty in precision medicine. METHODS A systematic search of the literature was conducted in three databases (Pubmed, Web of Science, and Jstor) and complemented with a systematic hand-search. The initial search provided 1.252 items of which 51 articles for selected as eligible for further analysis. These articles were coded with MAXQDA and categorized into four main themes (a-d) of uncertainty. The main results were summarized and discussed with a view to the interrelations between different aspects and implications for precision medicine in practice. RESULTS The mapping of different aspects and sources of uncertainty leads to the key result that 'uncertainty' should be understood as a cluster concept. Uncertainties are identified in many different respects and situated at different levels: Most complexity-related issues (theme a) can best be understood as ontological ('world-sided') aspects of the uncertainty paradox. Conceptual (theme b) and evidence-related uncertainties (theme c) are situated on an epistemological or methodological level, addressing foundational and normative challenges related to knowledge production in precision medicine. Finally, theme (d) targets issues on the level of material precision medicine practices. These levels are helpful to understand the different dimensions of the uncertainty paradox. CONCLUSIONS Uncertainty may not merely be a transient effect of the novelty of the precision medicine paradigm. Rather, it should be seen as a consequence of the ontological, epistemological and practical complexity of precision medicine, implying that uncertainty will not necessarily be reduced by more research. This finding encourages further investigations to better understand the interactions among various factors and aspects of uncertainty in precision medicine and the resulting implications for research and medical practice.
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Affiliation(s)
- Simon Lohse
- Institute for Science in Society, Radboud University, Nijmegen, The Netherlands.,Institute for History of Medicine and Science Studies, University of Lübeck, Lübeck, Germany.,Centre for Ethics and Law in the Life Sciences, Leibniz University Hannover, Hannover, Germany.,African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Johannesburg, South Africa
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Eachempati P, Büchter RB, Ks KK, Hanks S, Martin J, Nasser M. Developing an integrated multilevel model of uncertainty in health care: a qualitative systematic review and thematic synthesis. BMJ Glob Health 2022; 7:bmjgh-2021-008113. [PMID: 35501069 PMCID: PMC9062775 DOI: 10.1136/bmjgh-2021-008113] [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: 11/25/2021] [Accepted: 03/07/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Uncertainty is an inevitable part of healthcare and a source of confusion and challenge to decision-making. Several taxonomies of uncertainty have been developed, but mainly focus on decisions in clinical settings. Our goal was to develop a holistic model of uncertainty that can be applied to both clinical as well as public and global health scenarios. Methods We searched Medline, Embase, CINAHL, Scopus and Google scholar in March 2021 for literature reviews, qualitative studies and case studies related to classifications or models of uncertainty in healthcare. Empirical articles were assessed for study limitations using the Critical Appraisal Skills Programme (CASP) checklist. We synthesised the literature using a thematic analysis and developed a dynamic multilevel model of uncertainty. We sought patient input to assess relatability of the model and applied it to two case examples. Results We screened 4125 studies and included 15 empirical studies, 13 literature reviews and 5 case studies. We identified 77 codes and organised these into 26 descriptive and 11 analytical themes of uncertainty. The themes identified are global, public health, healthcare system, clinical, ethical, relational, personal, knowledge exchange, epistemic, aleatoric and parameter uncertainty. The themes were included in a model, which captures the macro, meso and microlevels and the inter-relatedness of uncertainty. We successfully piloted the model on one public health example and an environmental topic. The main limitations are that the research input into our model predominantly came from North America and Europe, and that we have not yet tested the model in a real-life setting. Conclusion We developed a model that can comprehensively capture uncertainty in public and global health scenarios. It builds on models that focus solely on clinical settings by including social and political contexts and emphasising the dynamic interplay between different areas of uncertainty.
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Affiliation(s)
- Prashanti Eachempati
- Department of Prosthodontics, Faculty of Dentistry, Manipal University College Malaysia, Bukit Baru, Malaysia
| | - Roland Brian Büchter
- Institute for Research in Operative Medicine (IFOM), Faculty of Health-School of Medicine, Witten/Herdecke University, Cologne, Nordrhein-Westfalen, Germany
| | - Kiran Kumar Ks
- Department of Prosthodontics, Faculty of Dentistry, Manipal University College Malaysia, Bukit Baru, Malaysia
| | - Sally Hanks
- Peninsula Dental School, Faculty of Health, University of Plymouth, Plymouth, UK
| | - John Martin
- Sustainable Earth Institute, University of Plymouth, Plymouth, UK
| | - Mona Nasser
- Peninsula Dental School, Faculty of Health, University of Plymouth, Plymouth, UK
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The use of cognitive task analysis in clinical and health services research — a systematic review. Pilot Feasibility Stud 2022; 8:57. [PMID: 35260195 PMCID: PMC8903544 DOI: 10.1186/s40814-022-01002-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 02/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background At times, clinical case complexity and different types of uncertainty present challenges to less experienced clinicians or the naive application of clinical guidelines where this may not be appropriate. Cognitive task analysis (CTA) methods are used to elicit, document and transfer tacit knowledge about how experts make decisions. Methods We conducted a methodological review to describe the use of CTA methods in understanding expert clinical decision-making. We searched MEDLINE, EMBASE and PsycINFO from inception to 2019 for primary research studies which described the use of CTA methods to understand how qualified clinicians made clinical decisions in real-world clinical settings. Results We included 81 articles (80 unique studies) from 13 countries, published from 1993 to 2019, most commonly from surgical and critical care settings. The most common aims were to understand expert decision-making in particular clinical scenarios, using expert decision-making in the development of training programmes, understanding whether decision support tools were warranted and understanding procedural variability and error identification or reduction. Critical decision method (CDM) and CTA interviews were most frequently used, with hierarchical task analysis, task knowledge structures, think-aloud protocols and other methods less commonly used. Studies used interviews, observation, think-aloud exercises, surveys, focus groups and a range of more CTA-specific methodologies such as the systematic human error reduction and prediction approach. Researchers used CTA methods to investigate routine/typical (n = 64), challenging (n = 13) or more uncommon, rare events and anomalies (n = 3). Conclusions In conclusion, the elicitation of expert tacit knowledge using CTA has seen increasing use in clinical specialties working under challenging time pressures, complexity and uncertainty. CTA methods have great potential in the development, refinement, modification or adaptation of complex interventions, clinical protocols and practice guidelines. Registration PROSPERO ID CRD42019128418. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01002-6.
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Djulbegovic B. Ethics of uncertainty. PATIENT EDUCATION AND COUNSELING 2021; 104:2628-2634. [PMID: 34312034 DOI: 10.1016/j.pec.2021.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 06/13/2023]
Abstract
Uncertainty is inherent in clinical medicine. However, just because absolute certainty is unachievable does not mean that rational and optimal decisions cannot be made. It is argued that we need to distinguish legitimate from illegitimate scientific uncertainties that are generated by manufacturing doubts aiming to create mis- and disinformation. The attempt to create doubts implies that actions under uncertainties are impossible. Such a belief ultimately harms public, which requires reasoned actions within a context of genuine scientific and medical uncertainties. The latter indicates that rational decisions, even in the absence of guaranteed absolute certainty, are not only possible but, on average, beneficial both for society and individuals.
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Affiliation(s)
- Benjamin Djulbegovic
- Beckman Research Institute, Department of Computational & Quantitative Medicine, City of Hope, 1500 East Duarte Rd., Duarte, CA, USA; Division of Health Analytics, 1500 East Duarte Rd., Duarte, CA, USA; Evidence-based Medicine & Comparative Effectiveness Research, 1500 East Duarte Rd., Duarte, CA, USA.
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Epstein RM. Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind. PATIENT EDUCATION AND COUNSELING 2021; 104:2635-2642. [PMID: 34334265 DOI: 10.1016/j.pec.2021.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown"). DISCUSSION Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement. CONCLUSION For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, Department of Family Medicine, and Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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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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Dwan C, Willig C. Existential uncertainty in health care: A concept analysis. J Eval Clin Pract 2021; 27:562-570. [PMID: 33474766 DOI: 10.1111/jep.13536] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/11/2020] [Accepted: 01/01/2021] [Indexed: 12/17/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES According to an influential taxonomy of varieties of uncertainty in health care, existential uncertainty is a key aspect of uncertainty for patients. Although the term "existential uncertainty" appears across a number of disciplines in the research literature, its use is diffuse and inconsistent. To date there has not been a systematic attempt to define it. The aim of this study is to generate a theoretically-informed conceptualisation of existential uncertainty within the context of an established taxonomy. METHOD Existential uncertainty was subjected to a concept analysis, which drew on existing uses of the term across multiple disciplines as well as insights from uncertainty theory more broadly and from the existential therapy literature to generate a tentative definition of the concept. Antecedents, consequences, and empirical referents of existential uncertainty were also identified. A model case was described as well as a borderline case and a related case in order to illustrate and delineate the concept. RESULTS Existential uncertainty is conceptualised as an awareness of the undetermined but finite nature of one's own being-in-the-world, concerned primarily with identity, meaning, and choice. This awareness is fundamental and ineradicable, and manifests at different levels of consciousness. CONCLUSION Humans rely on identity, worldview, and a sense of meaning in life as ways of managing the ineradicable uncertainty of our being-in-the-world, and these can be challenged by a serious diagnosis. It is important that medical professionals acknowledge issues around existential uncertainty as well as issues around scientific uncertainty, and recognise when patients might be struggling with these. Further research is required to identify ways of measuring existential uncertainty and to develop appropriate interventions, but it is hoped that this conceptualisation provides a useful first step towards that goal.
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Affiliation(s)
- Conor Dwan
- Department of Psychology, City, University of London, London, UK
| | - Carla Willig
- Department of Psychology, City, University of London, London, UK
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Plebani M, Padoan A, Sciacovelli L. Measurement uncertainty: light in the shadows. ACTA ACUST UNITED AC 2020; 58:1381-1383. [DOI: 10.1515/cclm-2020-0134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mario Plebani
- Department of Laboratory Medicine , University-Hospital of Padova , 3218 Padova , Italy
- Department of Medicine-DIMED, Medical School , University of Padova , Padova , Italy
| | - Andrea Padoan
- Department of Medicine-DIMED, Medical School , University of Padova , Padova , Italy
- Department of Laboratory Medicine , University-Hospital of Padova , Padova , Italy
| | - Laura Sciacovelli
- Department of Laboratory Medicine , University-Hospital of Padova , Padova , Italy
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Mercuri M. Humility in the face of uncertainty. J Eval Clin Pract 2019; 25:173-175. [PMID: 30788895 DOI: 10.1111/jep.13116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Mathew Mercuri
- Department of Medicine, McMaster University, Hamilton, Canada
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