"It's okay to not know …" a qualitative exploration of faculty approaches to working with uncertainty

"With Great Responsibility Comes Great Uncertainty"

BACKGROUND

Uncertainty is inherent in medicine, and trainees are particularly exposed to the adverse effects of uncertainty. Previous work suggested that junior residents seek to leverage the support of supervisors to regulate the uncertainty encountered in clinical placements. However, a broader conceptual framework addressing uncertainty experience, from the sources of uncertainty to residents' responses, is still needed.

OBJECTIVE

To capture the spectrum of uncertainty experiences in medical residents, providing an integrative framework that considers the influence of specialties and training stages on their experience with clinical uncertainty.

DESIGN

We used Hillen's uncertainty tolerance framework to conduct a thematic template analysis of individual and focus group interviews, identifying themes and subthemes reflecting residents' experience of clinical uncertainty.

PARTICIPANTS

Medical residents from diverse medical specialty training programs, across five French medical schools.

APPROACH

Qualitative study driven by an interpretivist research paradigm.

RESULTS

Twenty residents from all years of medical residency and diverse medical specialties were interviewed during three focus groups and five individual interviews. They described managing treatments, making ethical decisions, and communicating uncertainty, as their major sources of uncertainty. We identified residents' delayed response to uncertainty as a key theme, fostering the development of experiential learnings. Prior clinical experience was a key determinant of uncertainty tolerance in medical residents. Entrusting residents with responsibilities in patient management promoted their perception of self-efficacy, although situations of loneliness resulted in stress and anxiety.

CONCLUSION

Residents face significant uncertainty in managing treatments, ethical decisions, and communication due to limited clinical experience and growing responsibilities. Scaffolding their responsibilities and clearly defining their roles can improve their comfort with uncertainty. To that extent, effective supervision and debriefing are crucial for managing emotional impacts and fostering reflection to learn from their uncertain experiences.

Evaluation and Comparison of Tolerance of Ambiguity in Veterinary Pathology Professionals and Trainees

Ambiguity is ubiquitous in veterinary medicine, including in clinical and anatomic pathology. Tolerance of ambiguity (TOA) relates to how individuals navigate uncertainty. It is associated with psychological well-being in health professionals yet has been little investigated in veterinarians or veterinary pathologists. In this study, we used the Tolerance of Ambiguity of Veterinary Students (TAVS) scale and eight previously evaluated items specific to clinical pathology to evaluate and compare TOA in pathology professionals and trainees. We hypothesized that scores would be higher (reflecting greater TOA) for professionals than for trainees, that scores would increase with years of diagnostic experience for professionals and year of study for trainees, and that scores would be higher for clinical than anatomic pathologists due to the frequent ambiguity of clinical pathology practice. One hundred eighty one pathology professionals and trainees participated. TAVS scores were significantly higher for professionals than for trainees, and scores increased significantly with year of experience for professionals but not with year of study for trainees. When comparing disciplines, TAVS scores for all clinical pathologists were significantly lower than scores for all anatomic pathologists. Scores for clinical pathology specific items showed similar trends to TAVS scores, except when comparing disciplines (clinical pathologists tended to have higher scores for these items). Results suggest pathology professionals become more tolerant of ambiguity throughout their careers, independent of increasing TOA with age, and that navigating ambiguity might be more difficult for trainees than for professionals. Educational interventions might help trainees learn to successfully navigate ambiguity, which could impact psychological well-being.

Learning While in Work: Exploring Influences on Engagement and Achievement in Veterinary Professionals Studying Remotely

Remote learning provides flexible opportunities for veterinarians and veterinary technicians to undertake professional development qualifications alongside their work. Although this offers advantages in accessing courses that may otherwise not be available, online provision may not suit all learners equally. Using thematic analysis of semi-structured interviews with a group of veterinary educators (faculty, veterinarians, and veterinary nurses/technicians), this study explored their engagement and learning outcome achievements from a post-graduate certificate in veterinary education. Participants were highly motivated to engage, but their engagement was compromised when they had low levels of professional autonomy (particularly in scheduling study time and opportunities to put learning outcomes into practice). Some participants also found engagement more challenging when they experienced academic uncertainty or a reduction in social learning opportunities. A lot of the learning occurred in the participants applying taught content to practice, and therefore the education interface extended to the workplace. Educators teaching similar students using an online-only format should thus recognize the learners' workplaces as an important part of the learning environment and find ways to help them learn in that context. Learner engagement is also supported by interventions to foster social connections, scaffolded strategies for self-direction, and helping them to balance achievement against wellbeing goals.

Utilizing Stakeholder Consultations to Identify Context-Specific Professional Skills for Veterinary Graduates in Bangladesh

Despite professional skills being part of the Day One Competences published by national as well as international accreditation bodies, veterinary schools in Bangladesh have limited associated teaching within their curricula. Therefore, our study aimed to identify the most important professional skills for veterinarians in Bangladesh through local consultation to inform future initiatives to change the curriculum. Eleven focus groups were conducted with 45 stakeholders who included veterinarians who supervise students on workplacements, faculty, recent graduates, final year students, and clients. The audio recordings were transcribed, translated into English from Bengali and analyzed using an inductive thematic approach. Professional skills were considered essential by all stakeholder groups. The most important professional skills were identified as communication, ethical conduct, teamwork, career options, financial management skills, lifelong learning, time management and self-appraisal. One of the best opportunities to practice many of the skills was identified as being during final year workplacements, while participating in extracurricular activities, learning by observing others and self-motivation were also considered valuable. Participants identified a need for more formal professional skills teaching within the curriculum. Challenges included finding space in the curriculum, raising awareness amongst university academics and engaging students and faculty in the new initiatives. This study has identified the most important professional skills in our context. Consultation with relevant regional stakeholders was crucial and will inform curricular change. The results are being used in the development of professional skills courses with the long-term aim of better preparing our graduates for their future careers.

Measurement of uncertainty tolerance revisited

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Enduring uncertainties. Medical accounts on caring for young people with variations of sex characteristics

Objectives

The diagnosis of intersex or variations of sex characteristics (VSC) often has a big impact on families who fear social stigmatization. Research has shown that intersex populations often experience important health disparities and that poor mental health and daily function are common among youth with VSC. The present study aimed to explore what healthcare professionals of adolescents and young adults (AYA) with VSC find important in terms of care to this group of patients.

Methods

Semi-structured interviews were conducted with Swiss healthcare providers involved in the care of youth born with an intersex variation. The qualitative data were analyzed using reflexive thematic analysis.

Results

Analysis resulted in six major themes: (1) With regard to patients' and families lived experiences, interviewees reported that fertility was as a major issue for parents but not for intersex youth as they were said to live in the moment. (2) Respondents considered various forms of psycho-social care (professional support, peer support and informal support from family and friends) to be of fundamental importance for their patients, but many of them seemed critical about support from advocacy groups and activists. All healthcare providers reported significant gaps in (3) the transition process and (4) the establishment of multidisciplinary care teams due to structural, provider- and patient-related barriers. (5) Participants were in favor of a more holistic and patient-centred care approach and (6) were critical about the medicalized use of DSD (disorder of sex development) with patients and families.

Conclusion

These findings suggest that although clinicians work hard to implement a holistic approach to care, their intentions are often undercut by a desire to hold a position of medical control. Healthcare professionals need to come to see medical uncertainty not only as a threat but also as an opportunity.

Hope in the uncertainties and certainty for parents of children with rare neurological disorders. Part I (of 3): Uncertainty

This is the first of three articles exploring the aspects of clinical care for children with rare neurological disorders including uncertainties old and new. The disruptive technologies of genomic sequencing and advanced therapeutics such as gene-based therapies offer parents of children with severe but rare neurological conditions for the first-time unprecedented opportunities for 'precision medicine'. At the same time, the realities of limited genomic diagnostic yields and not infrequent detection of variants of uncertain significance, lack of natural history study data and management guidelines for individually rare neurogenetic conditions, means that high pre-genomic test expectations are all too often replaced by an accumulation of new uncertainties. This can add to the chronic traumatic stress experienced by many families but may also have under-recognised impacts for their clinicians, contributing to 'burn-out' and attendant negative psychosocial impacts. This first article aims to address how clinicians might manage the accumulation of uncertainties to be more helpful to patients and their families. Moreover, it seeks to address how clinicians can move forward providing compassionate care to their patients and a little more consideration for themselves.