Understanding uncertainty in medicine: concepts and implications in medical education

Essential New Complexity-Based Themes for Patient-Centered Diagnosis and Treatment of Dementia and Predementia in Older People: Multimorbidity and Multilevel Phenomenology

Dementia is a highly prevalent condition with devastating clinical and socioeconomic sequela. It is expected to triple in prevalence by 2050. No treatment is currently known to be effective. Symptomatic late-onset dementia and predementia (SLODP) affects 95% of patients with the syndrome. In contrast to trials of pharmacological prevention, no treatment is suggested to remediate or cure these symptomatic patients. SLODP but not young onset dementia is intensely associated with multimorbidity (MUM), including brain-perturbating conditions (BPCs). Recent studies showed that MUM/BPCs have a major role in the pathogenesis of SLODP. Fortunately, most MUM/BPCs are medically treatable, and thus, their treatment may modify and improve SLODP, relieving suffering and reducing its clinical and socioeconomic threats. Regrettably, the complex system features of SLODP impede the diagnosis and treatment of the potentially remediable conditions (PRCs) associated with them, mainly due to failure of pattern recognition and a flawed diagnostic workup. We suggest incorporating two SLODP-specific conceptual themes into the diagnostic workup: MUM/BPC and multilevel phenomenological themes. By doing so, we were able to improve the diagnostic accuracy of SLODP components and optimize detecting and favorably treating PRCs. These revolutionary concepts and their implications for remediability and other parameters are discussed in the paper.

Working as a physiotherapist in a rapid response team: 'An emotional rollercoaster'

BACKGROUND AND INTRODUCTION

Rapid Response Teams (RRTs) are multidisciplinary, 'hospital at home' services which have developed over the last 10 years, aiming to improve recovery from illness more efficiently, prevent unnecessary hospital admission, and prevent early admission to residential care. However, little is known about the experience of professionals working in these roles.

PURPOSE

The aim of this study was to explore how working in an RRT is experienced and perceived by physiotherapists.

METHODS

This study used phenomenographically inspired methodology. Six participants who were working in RRTs were recruited to this study and all were working in the South of England. Data were collected via semi-structured interviews, and phenomenographic analysis was undertaken.

RESULTS

Participants working in RRTs described a range of varied, concrete lived-through experiences in addition to a more rhetorical discussion of how they conceptualized their work. Six main categories of description were generated from the analysis; each was assigned a metaphor. These included 'the detective,' 'the guru,' 'the lone ranger,' 'the team player,' 'the bricoleur,' and 'an emotional rollercoaster'; all categories were present with varied meanings. 'An emotional rollercoaster' was present within and throughout participants' descriptions of all other categories.

CONCLUSION

This study provides valuable insights into physiotherapists' experience and conceptualization of working within this discipline, which may have implications for physiotherapy practice, workforce development, new and current RR physiotherapy services, RRT health professionals, and physiotherapy education.

Mapping Educational uncertainty stimuli to support health professions educators' in developing learner uncertainty tolerance

Uncertainty is a feature of healthcare practice. In recognition of this, multiple health profession governing bodies identify uncertainty tolerance as a healthcare graduate attribute and evaluate uncertainty tolerance within new graduate cohorts. While it is clear that uncertainty tolerance development for healthcare learners is valued, gaps remain for practically addressing this within healthcare curricula. Guiding frameworks for practical approaches supporting uncertainty tolerance development in healthcare learners remains sparse, particularly outside of medicine and in certain geographical locations. As uncertainty tolerance is increasingly recognised as being, at least in part, state-based (e.g. contextually changeable)- a broader understanding of teaching practices supporting uncertainty tolerance development in diverse health professions is warranted. This study explored educators' teaching practices for purposefully stimulating learners' uncertainty tolerance. Semi-structured interviews investigated how academics at a single institution, from diverse fields and health professions, stimulate uncertainty across multiple learning contexts. Framework analysis identified three themes for stimulating uncertainty: Purposeful questioning, Forecasting uncertainty, and Placing learners in unfamiliar environments, with characterisation of these themes (and related subthemes) also described. Many of the identified themes align with aspects of existing learning theories suggesting that curricular frameworks supporting learner uncertainty tolerance development may be informed by theories beyond the boundaries of health professions education research.

Improving clinical reasoning and communication during handover: An intervention study of the BRIEF-C tool

BACKGROUND

Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers.

DESIGN

A pre-test post-test intervention study.

SETTING

Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital.

INTERVENTION

The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback.

MEASUREMENTS

Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods.

RESULTS

A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach's alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen's d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen's d=0.83).

CONCLUSION

This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.

Navigating Uncertainty in Clinical Practice: A Structured Approach

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

Resident training in psychopathology and uncertainty in a clinical situation

The central theme of this article is the way in which psychiatry physicians-in-training deal with uncertainty in the discussion of clinical cases in Mexico. Methodologically, it is approached from the field of clinical ethnography and the narrative interpretation of plots in performative actions where there are sequences of communicative exchanges. In this way, it focuses on a detailed description of situations where clinical cases are reviewed to decipher, explain, and understand intersubjective meanings in the face of the emergence of uncertainty, its management, and the implications on decisions and actions. The study finds that limitations within the field of psychiatry lie in the nosographic construction of disease and its translation into the diagnostic hypotheses made by clinicians, where there are wide margins of ambiguity. The strategies implemented in the face of uncertainty are use of drugs, the collegiate review of the case, and utilization of intuition as a spontaneous, preconscious daily practice. The specific case described here provides a microscopic observation of the complex scenarios in which uncertainty occurs in educational and teaching processes, clearly revealing how patient care is articulated. The narratives and their interpretation are materials for training/curriculum and psychiatric clinical practice.

Family Member Experiences in Intensive Care Units Care: Insights From a Family Involvement Tool Implementation Trial

Family involvement is widely considered an important part of patient care in the intensive care unit. From professional health care organizations, government, and hospital associations, there has been a cultural shift toward family presence as part of a wider commitment to patient-centered care. At the same time, the meaning and impact of family involvement in the intensive care unit setting remain opaque and under-studied. This study employed an ethnographic approach to better understand family involvement in practice and from the perspective of health care professionals and family members by studying an implementation trial of a family involvement tool in two intensive care units over 2 years. The findings revealed that an expanded and self-defined role for family members as carers in the intensive care unit challenged the current configuration of the nurse patient/family relationship and that family members were aware of these dynamics. While the intensive care unit implementation teams were both motivated to implement a novel way of facilitating family involvement, the processual, organizational, and contextual factors in the intensive care units largely determined the possibilities of its application. This suggests that interventions should address the specific context in which they are employed.

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.

Moderators uncertainty tolerance (UT) in healthcare: a systematic review

Uncertainty tolerance (UT) is integral to healthcare. Providers' responses to medical uncertainty has ramifications on the healthcare system, the healthcare provider and the patient. Understanding healthcare providers' UT, is important for improving patient-care outcomes. Understanding whether and to what extent it is possible to modulate individuals' perceptions and responses to medical uncertainty, can provide insights into mechanisms for support for training and education. The objectives of this review were to further characterize moderators of healthcare UT and explore moderator influences on the perceptions and responses to uncertainty experienced by healthcare professionals. Framework analysis of qualitative primary literature was conducted on 17 articles, focusing on the impacts of UT on healthcare providers. Three domains of moderators were identified and characterized relating to the healthcare provider's personal attributes, patient-derived uncertainty and the healthcare system. These domains were further categorized into themes and subthemes. Results suggest these moderators influence perceptions and responses to healthcare uncertainty across a spectrum ranging from positive to negative to uncertain. In this way, UT could be a state-based construct within healthcare settings and is contextually determined. Our findings further characterize the integrative model of uncertainty tolerance (IMUT) (Hillen Social Science and Medicine 180, 62-75, 2017) and provide evidence for the relationship between moderators and their influences on cognitive, emotional and behavioral responses to uncertainty. These findings provide a foundation for understanding the complex nature of the UT construct, add to theory development, and provide groundwork for future research exploring appropriate support for training and education in healthcare fields.

Less Likely Brainstorming: Using Language Models to Generate Alternative Hypotheses

A human decision-maker benefits the most from an AI assistant that corrects for their biases. For problems such as generating interpretation of a radiology report given findings, a system predicting only highly likely outcomes may be less useful, where such outcomes are already obvious to the user. To alleviate biases in human decision-making, it is worth considering a broad differential diagnosis, going beyond the most likely options. We introduce a new task, "less likely brainstorming," that asks a model to generate outputs that humans think are relevant but less likely to happen. We explore the task in two settings: a brain MRI interpretation generation setting and an everyday commonsense reasoning setting. We found that a baseline approach of training with less likely hypotheses as targets generates outputs that humans evaluate as either likely or irrelevant nearly half of the time; standard MLE training is not effective. To tackle this problem, we propose a controlled text generation method that uses a novel contrastive learning strategy to encourage models to differentiate between generating likely and less likely outputs according to humans. We compare our method with several state-of-the-art controlled text generation models via automatic and human evaluations and show that our models' capability of generating less likely outputs is improved.

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

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

Patient Perspectives on ADPKD

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease. It has been associated with a significant physical and psychological burden, leading to a reduced quality of life. The purpose of this literature review is to summarize the patient perspective on ADPKD based on the current published literature. A systematic literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Publications reporting a patient or caregiver/relative perspective of ADPKD were included. Sources searched included Medline (PubMed), Embase (Ovid), Cochrane Library, and Web of Science from inception to April 2022. This was followed by a subsequent reference and citation search. A total of 1011 articles were identified by the search process, with 28 studies included in the review. An inductive thematic analysis identified six key themes: diagnosis, monitoring, and screening; symptoms; lifestyle and dietary interventions; psychological, physical, and social impact; future planning; and interaction with the health care system. The findings of this review highlight the burden and uncertainty associated with ADPKD from a patient's perspective. This impacts patients and their caregivers/relatives at each stage of the patient's journey from screening to initiation of renal replacement therapy and future planning.

Choosing between the red and the blue pill. How do people decide when they face uncertainty regarding different treatment alternatives?

BACKGROUND

When we are faced with health challenges, we have to choose a treatment from several alternatives. Most of the time, we must make a choice even though some information regarding the options is missing. Previous research found that missing information systematically impacts our choices.

AIM

The present study investigated if context-related variables (type of information: advantages or costs, the label of the alternatives) and individual differences (moral purity, thinking style) have an impact on the way people make these kinds of choices. Methods: One hundred twenty-three students (52% males) had to make 27 decisions regarding their preferred alternative for treating various medical conditions. We manipulated the type of comparable information (i.e., regarding advantages, disadvantages, or costs), and the label of the treatment alternatives (i.e., abstract vs. recognizabletreatments). Additionally, we measured the participants' moral purity endorsement and thinking style via self-report questionnaires.

RESULTS

The results showed that context variables like the type of comparable information and the label of the alternatives are significant predictors of people's medical treatment choices. At the same time, self-reported measures were unrelated to the way people choose medical treatment.

CONCLUSION

The results highlight the importance of discussing the issue of missing information with healthcare consumers and patients.

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

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

'Don't think that we die from AIDS': Invisibilised uncertainty and global transgender health

The invisibilisation of social groups in health research and survey data is a source of medical uncertainty, long seen as a hallmark of the medical field. However, scholarship has not thoroughly assessed how medical uncertainty is structured by state-level processes and global health agendas, especially for people beyond the Global North. This article introduces invisibilised uncertainty as a type of medical uncertainty structured by global organisational and state-level priorities, which can invisibilise social groups and health problems from research and data collection, exacerbating medical uncertainty and health disparities for people worldwide. Based on 14 months of fieldwork in Thailand and in-depth interviews with 62 participants, the article illuminates how state-level processes and global clinical research agendas have structured knowledge gaps and uncertainties for Thai transgender women. As omissions in health research and data collection become embodied on a world scale, the article expands our understandings of how gendered health disparities are structured nationally and globally. It advances a sociology of medical ignorance by analysing the uneven landscape of holistic transgender health research, parsing how institutional dynamics can prioritise or invisibilise people and health issues in research and data, and structure uncertainties.

The Effect of an Elective Course in Medical Ethics on Medical Students' Tolerance for Ambiguity

AbstractPurpose: Tolerance for ambiguity (TFA) is a character trait that is associated with a multitude of benefits for physicians, including increased empathy, greater desire to work in underserved areas, fewer medical errors, enhanced psychological well-being, and lower rates of burnout. Furthermore, it has been shown that TFA is a malleable trait that can be enhanced with interventions such as art courses and group reflection. This study describes the utility of a six-week medical ethics elective course in increasing TFA in first- and second-year medical students.Methods: First- and second-year medical students were enrolled in an elective medical ethics course at Cooper Medical School of Rowan University that guided students in critical thinking, group discussion, and respectful debate regarding various ethical dilemmas in medicine. Students took a validated survey before and after course completion to measure TFA. The average pre- and post-course scores for each semester, as well as the total cohort of 119 students, were compared using paired t-tests.Results: A statistically significant improvement in TFA scores was observed in the overall cohort, as well as in each individual semester of the medical ethics elective course offering.Conclusion: A six-week elective course in medical ethics can significantly improve medical students' TFA.

A qualitative approach to identify clinical uncertainty in practicing physicians and clinical residents

BACKGROUND

Clinical decision-making is not only stressful to physicians, but also to patients and even their companions. Thus, managing uncertainty in clinical decision-making is essential which requires knowing its origins. Therefore, this study aimed to understand determinants of uncertainty in clinical decision-making from the perspective of clinical physicians.

MATERIALS AND METHODS

This is a qualitative study which is done during October to November 2020. An in-depth interview is performed with 24 specialists of clinical groups including obstetrics, surgery, internal medicine, and pediatrics, working in teaching hospitals affiliated to Iran University of Medical Sciences. All the interviews were recorded, transcribed and analyzed according to the steps suggested by Graneheim and Lundman. The interviews were analyzed through comparative method. Then, the interviewer created initial codes, categories, and key concepts and sent them to fourteen physicians for member check.

RESULTS

According to the participants' view, determinants of uncertainty in clinical decision-making consisted of three themes: individual determinants, dynamics of medical sciences, and diagnostic and instrumental constraint. Individual determinants can be related to the physician or patient. The dynamics of medical sciences could be explained in two categories: variation of medical science and complexity. Diagnostic and instrumental constraint category could be also explained in subcategories such as lack of efficient diagnostic tests and unknown etiology.

CONCLUSION

To curb uncertainty, the more accessible way is considering interventional programs with a focus on individual determinants related to physicians, such as strengthening doctor-patient relationships, and considering related mandatory retraining courses to reduce insufficient knowledge of physicians.

Ambiguity and uncertainty tolerance and psychological needs of medical students: A cross-sectional survey

BACKGROUND

Although the ubiquitous presence of ambiguity and uncertainty in medical practice is widely acknowledged, a greater understanding of contextual factors for educators to consider in helping students learn to respond to ambiguity and uncertainty adaptively is needed. Drawing on self-determination theory, the purpose of this study was to explore the unique roles of basic psychological needs-autonomy, competence and relatedness-in medical students' tolerance of ambiguity and uncertainty.

METHODS

This was a cross-sectional survey study of third-year medical students (n = 70) at a large Canadian university. In regression analysis, the three basic psychological needs were entered as predictors of medical students' tolerance of ambiguity and uncertainty while controlling for students' age and gender.

RESULTS

Of the three needs, the need for competence was determined to be statistically significant in relation to students' tolerance of ambiguity and uncertainty (β = 0.326; p = 0.038). The needs for autonomy and relatedness were determined to be not statistically significant (β = -0.170; p = 0.274 and β = 0.154; p = 0.218, respectively).

DISCUSSION

We observed that medical students, who experienced satisfaction of the need for competence in the learning environment, reported greater tolerance of ambiguity and uncertainty. Potential implications for medical education are discussed, based on self-determination theory.

Visual art-based training in undergraduate medical education: A systematic review

BACKGROUND

Visual art has been increasingly incorporated into medical education and has been shown to enhance important competencies, such as empathy. However, limited evidence on effective visual art program design and evaluation processes remain. This systematic review examines the format, content, and espoused outcomes of visual art-based training programs in undergraduate medical education.

METHODS

A comprehensive literature search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ProQuestERIC on undergraduate medical education and visual arts retrieved 1703 articles published from 2014 to 2020. After reviewing inclusion and exclusion criteria, 23 articles were chosen for full review and synthesis.

RESULTS

Program format and content varied, ranging from 1-day specific competency focused programs to well-structured comprehensive 6-12-week programs. 6 areas of program foci were identified: observation skills, empathy, tolerance to uncertainty, cultural sensitivity, team building and collaboration, and wellness and resiliency. Although several programs used validated measures to assess skills acquisition, they seldom addressed long-term outcomes.

CONCLUSIONS

Our findings indicate that visual art-based education hold a promise to enhance important competencies in medical education, particularly empathy. Clinical observation, in particular, had the strongest evidence of its effectiveness compared to the other competencies. Future programs incorporating visual arts will benefit from a longitudinal (greater than 6 weeks) program which incorporates guided artworks, reflection exercises, and a group discussion to provide a stronger foundation for the development of core competencies. We propose using validated scales to measure outcomes in future studies and follow-up with participants to better assess Kirkpatrick Level 3 and 4 outcomes.

Towards a medical school curriculum for uncertainty in clinical practice

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

Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time: A clinical review and management algorithms

Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.

A Baby at All Costs? Exploring the Use and Provision of Unproven Adjuvant Treatments in the Context of IVF

The year 2018 marked 40 years since the birth of Louise Brown, the first baby born as a result of pioneering in vitro fertilization (IVF) treatment. Since then, advances have seen a wide range of reproductive technologies emerge into clinical practice, including adjuvant treatments often referred to as IVF "add-ons." However, these "optional extras" have faced growing criticism, especially when they have often come at additional financial cost to the patient and have little evidence supporting their efficacy to improve pregnancy or birth rates. Despite this, according to the latest national patient survey by the Human Fertilisation and Embryology Authority, three quarters of patients who had fertility treatment in the United Kingdom in the past two years had at least one type of treatment add-on highlighting the growing demand for these interventions. This article uses a psychosocial perspective to consider the motivations behind patient and clinician behavior along with the wider societal and economic factors that may be impacting upon the increase in the use of adjuvant treatments in fertility clinics more widely. It suggests the reasons fertility patients use unproven "optional extras" are complex, with interpersonal, psychological, and social factors intertwining to generate an increase in the use of IVF add-ons.

Examining the Association between Evidence-Based Practice and Burnout among Spanish Physical Therapists: A Cross-Sectional Study

The aim of this study was to quantify the level of burnout and competence for evidence-based practice among Spanish physical therapists and to determine if there is a relationship between these and other socio-professional factors. A cross-sectional study with 472 Spanish Physiotherapists. An electronic survey was conducted that included the Maslach Burnout Inventory, Evidence-Based Practice Questionnaire and sociodemographic data. The three subscales of the Burnout correlated with attitude and total Evidence-Based Practice Questionnaire. Attitude and practice for evidence-based practice, educational level and experience were the variables that showed the greatest influence on burnout. Burnout and the degree of evidence-based practice were identified as being discretely related. Specifically, it seems that the evidence-based practice could improve the lack of personal accomplishment, meaning that through interventions perceived as more effective and advantageous, a sense of mastery and self-efficacy is experienced.

Factors Related to Self-Reported Distress Experienced by Physicians During Their First COVID-19 Triage Decisions

OBJECTIVE

The aim of this study was to identify factors associated with distress experienced by physicians during their first coronavirus disease 2019 (COVID-19) triage decisions.

METHODS

An online survey was administered to physicians licensed in New York State.

RESULTS

Of the 164 physicians studied, 20.7% experienced severe distress during their first COVID-19 triage decisions. The mean distress score was not significantly different between physicians who received just-in-time training and those who did not (6.0 ± 2.7 vs 6.2 ± 2.8; P = 0.550) and between physicians who received clinical guidelines and those who did not (6.0 ± 2.9 vs 6.2 ± 2.7; P = 0.820). Substantially increased odds of severe distress were found in physicians who reported that their first COVID-19 triage decisions were inconsistent with their core values (adjusted odds ratio, 6.33; 95% confidence interval, 2.03-19.76) and who reported having insufficient skills and expertise (adjusted odds ratio 2.99, 95% confidence interval 0.91-9.87).

CONCLUSION

Approximately 1 in 5 physicians in New York experienced severe distress during their first COVID-19 triage decisions. Physicians with insufficient skills and expertise, and core values misaligned to triage decisions are at heightened risk of experiencing severe distress. Just-in-time training and clinical guidelines do not appear to alleviate distress experienced by physicians during their first COVID-19 triage decisions.

Agreement and Disparities between Women and Stop-Smoking Specialists about How to Promote Adherence to Nicotine Replacement Therapy in Pregnancy

Evidence for the effectiveness of nicotine replacement therapy (NRT) for smoking-cessation in pregnancy is weak. This has been attributed to insufficient dosing and low adherence. This study investigated the acceptability of key messages and delivery modes for a behavioral intervention to increase NRT adherence in pregnancy. Semi-structured telephone interviews were carried out with pregnant or postpartum women aged ≥16 from across England, who had been offered NRT during pregnancy as part of a quit attempt and who struggled to quit (n = 10), and a focus group with stop-smoking specialists from across England (n = 6). The two data sources were coded separately using a thematic approach and then integrated to compare perspectives. Women and specialists agreed on message tone and delivery modes. However, views diverged on the most influential sources for certain messages and whether some information should be given proactively or reactively. There was also disagreement over which messages were novel and which were routinely delivered. This study demonstrates the value of capturing and integrating different perspectives and informational requirements when developing behavior-change interventions. The findings provide useful insights for designing a pregnancy-specific NRT adherence intervention that is acceptable to both those who will deliver and receive it.

Ten tips for improving your clinical practice during the COVID-19 pandemic

PURPOSE OF REVIEW

This review provides ten tips for improving clinical practice during COVID-19 as pandemic fatigue begins to complicate personal and professional lives of clinicians.

RECENT FINDINGS

COVID-19 has created unique and unexpected challenges to healthcare delivery, but has also provided opportunities for re-evaluation of practice patterns to optimize high-value practices. With ongoing uncertainty, key factors to appreciate for patient and population health include the continued touchstones of empathy and compassion, the use of effective risk communication with shared clinical decision-making when appropriate, attention to resource stewardship and vulnerable populations, importance of health literacy and need for critical assessment of media and medical literature to mitigate misinformation, and the hidden costs of the pandemic on children. Although there has been some international concern for allergic reactions to the recently approved Pfizer-BioNTech COVID-19 vaccine, neither the United States Pfizer-BioNTech or Moderna COVID-19 vaccine emergency use authorizations exclude patients without a specific allergy to a vaccine component from receiving vaccination.

SUMMARY

Practical adjustments to practice during COVID-19 are feasible and acceptable. Experience during COVID-19 reinforces the critical need for human connection while providing care and service in every encounter.

Diagnostic and investigative approach of consultant neurologists in a real-world clinical setting: A pilot study

PURPOSE

Whilst core curricula in neurology are nationally standardised, in real-world clinical practice, different approaches may be taken by individual consultants. The aims of this study were to investigate differences by assessing: (a) variance in diagnostic and investigative practice, using a case-based analysis of inter-rater agreement; (b) potential importance of any differences in terms of patient care; (c) relationships between clinical experience, diagnostic certainty, diagnostic peer-agreement and investigative approach. The objective was to develop novel individualised metrics to facilitate reflection and appraisal.

METHODS

Three neurologists with 6-23 years' experience at consultant level provided diagnosis, certainty (10-point Likert scale), and investigative approach for 200 consecutive general neurology outpatients seen by a newly qualified consultant in 2015. Diagnostic agreement was evaluated by percentage agreement. The potential importance of any diagnostic differences on patient outcome was assigned a score (6-point Likert scale) by the evaluating neurologist. Associations between diagnostic agreement, certainty and investigative approach were assessed using Spearman correlation, logistic and ordinal regression, and reported as individualised metrics for each rater.

RESULTS

Diagnostic peer-agreement was 3/3, 2/3 and 1/3 in 55.5%, 31.0% and 13.5% of cases, respectively. In 15.5%, differences in patient management were judged potentially important. Investigation rates were 42%-73%. Mean diagnostic certainty ranged from 6.63/10 (SD 1.98) to 7.72/10 (SD 2.20) between least and most experienced consultants. Greater diagnostic certainty was associated with greater diagnostic peer-agreement (individual-rater regression coefficients 0.33-0.44, P < .01) and lower odds of arranging investigations (individual-rater odds ratios 0.56-0.71, P < .01).

CONCLUSIONS

It appears that variance in diagnostic and investigative practice between consultant neurologists exists and may result in differing management. Mean diagnostic certainty was associated with greater diagnostic peer-agreement and lower investigation rates. Metrics reflecting concordance with peers, and relationships to diagnostic confidence, could be developed in larger cohorts to inform reflective practice.

What is the impact of the Rashomon approach in primary care education?: An educational case report of implementing dialogue and improvisation into medical education

BACKGROUND

The excessive sub-divided or concrete pre-determined objectives found in the technological approach in contemporary medical education curricula may hinder the students' spontaneous learning about diverse needs and values in care. However, medical professionals must learn the diversity for care or a variety of social factors of the patients influencing decision making in daily practice.

METHODS

We introduced a new method of curriculum development called the Rashomon approach. For testing the Rashomon approach, educational activities to teach the diversity in primary care were developed in four modules: 1) explication of the competency without specifying sub-objectives; 2) dialogue among multiple professional students; 3) visits and interviews of the patients; 4) dialogue with teachers' improvisation. The students' outcomes and responses were quantitatively and qualitatively analyzed.

RESULTS

A total of 135 medical students joined this study in 2017. The descriptive data suggested that the key concepts of diversity in primary care were fully recognized and that the pre-determined general goals were achieved. Scores on the understanding of social factors in medicine, respect for other professionals, professional identity, and satisfaction with the course were very high.

CONCLUSION

Instead of the technological approach, the Rashomon approach, in which only a general goal guides educational activities was used in this research. Improvisation and dialogue fit the approach and were potentially effective activities to learn the multifaceted practice of medicine. In an era of competency-based education, the Rashomon approach could be a very useful framework in primary care education.

Ambiguity Tolerance and Prospective Specialty Choice Among Third-Year Medical Students

Introduction

Poor tolerance of ambiguity is consequential in clinical practice, and has been linked to avoidance of family medicine, in which there is inherently more ambiguity. This study aimed to investigate the relationship between tolerance of ambiguity and prospective specialty choice of medical students in their third year of medical school. This stage of medical training is of particular importance as students develop clinical reasoning skills and encounter clinical ambiguity.

Methods

This was a cross-sectional study using an online survey. Sixty-one third-year medical students (62% response rate) from a large Canadian university completed the survey with a validated measure of ambiguity tolerance (the 29-item Tolerance of Ambiguity in Medical Students and Doctors scale) and their top three specialty choices. Specialty choices were subsequently grouped into two categories: family medicine (FM) and non-family medicine (non-FM) specialties.

Results

There was no significant mean difference in tolerance of ambiguity between students who reported interest in FM and students interested in non-FM specialties. Similarly, we observed no significant difference in tolerance of ambiguity between female and male students. Older students reported higher levels of ambiguity tolerance. Older students were also more likely to report FM as one of their top three specialty choices.

Conclusion

Qualitative studies are needed to explore possible reasons for the observed results, including the effects of digital information resources and clinical decision-making tools on medical students' ambiguity tolerance. Medical educators should be aware that some students may require explicit training in how to respond to ambiguity.

Supportive psychological intervention on psychological disorders in clinical medicine students with English Learning Difficulties: A protocol of systematic review

BACKGROUND

This study aims to examine the effect of supportive psychological intervention (SPI) on psychological disorders (PD) in clinical medicine students (CMS) with English Learning Difficulties (ELD).

METHODS

We will perform a comprehensive literature search from the following databases: Cochrane Library, MEDLINE, EMBASE, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. All databases will be performed from their inception to the present without language limitation by 2 independent reviewers. We will also look for grey literature, such as conference proceedings, dissertations or theses. Newcastle-Ottawa Scale will be used to assess study quality, and RevMan 5.3 software will be applied to carry out statistical analysis.

RESULTS

This study will summarize the most recent evidence to assess the effect of SPI on PD in CMS with ELD.

CONCLUSION

This study may provide helpful evidence of SPI on PD in CMS with ELD. OSF REGISTRATION NUMBER:: osf.io/tah2s.

Learning to manage uncertainty: supervision, trust and autonomy in residency training

Sociologists have debated whether and how medical trainees are socialised to deal with uncertainty for decades. Recent changes in the structure of medical education, however, have likely affected the ways that resident physicians learn to manage uncertainty. Through ethnographic case studies of academic medical centres in Switzerland and the United States, this article provides new insights into the processes through which residents learnt to manage uncertainty. These processes included working under supervision, developing relationships of trust with supervisors and gaining autonomy to practise independently. As a result, residents developed different attitudes towards uncertainty. Residents at the Swiss medical centre tended to develop a more pragmatic attitude and viewed uncertainty as something to be addressed and controlled. On the other hand, residents at the American medical centre tended to develop an acceptive attitude towards uncertainty. More broadly, residents learnt to reproduce their supervisors' attitudes towards uncertainty. This article therefore provides new perspectives on continuity and the reproduction of social phenomena in medical education.

EMKLAS: A New Automatic Scoring System for Early and Mild Keratoconus Detection

Purpose

Create a unique predictive model based on a set of demographic, optical, and geometric variables with two objectives: classifying keratoconus (KC) in its first clinical manifestation stages and establishing the probability of having correctly classified each case.

Methods

We selected 178 eyes of 178 subjects (115 males; 64.6%; 63 females, 35.4%). Of these, 74 were healthy control subjects, and 104 suffered from KC according to the RETICS grading system (61 early KC, 43 mild KC). Only one eye from each patient was selected, and 27 different parameters were studied (demographic, clinical, pachymetric, and geometric). The data obtained were used in an ordinal logistic regression model programmed as a web application capable of using new patient data for real-time predictions.

Results

EMKLAS, an early and mild KC classifier, showed good training performance figures, with 73% global accuracy and a 95% confidence interval of 65% to 79%. This classifier is particularly accurate when validated by an independent sample for the control (79%) and mild KC (80%) groups. The accuracy of the early KC group was remarkably lower (69%). The variables included in the model were age, gender, corrected distance visual acuity, 8-mm corneal diameter, and posterior minimum thickness point deviation.

Conclusions

Our web application allows fast, objective, and quantitative assessment of early and mild KC in detection and classification terms and assists ophthalmology professionals in diagnosing this disease.

Translational Relevance

No single gold standard exists for detecting and classifying preclinical KC, but the use of our web application and EMKLAS score may aid the decision-making process of doctors.

Need for cognitive closure, tolerance for ambiguity, and perfectionism in medical school applicants

BACKGROUND

Physicians have to deal with uncertainty on a daily basis, which requires high tolerance for ambiguity. When medical decisions have to be made in ambiguous situations, low levels of need for cognitive closure and high levels of adaptive perfectionism are beneficial. It might be useful to measure such personality traits during medical school selection processes. In our study, we explored the expression of need for cognitive closure, tolerance for ambiguity, and perfectionism in medical school applicants who participated in a multiple mini-interview selection process with respect to the final decision of admission or rejection.

METHODS

After participating in the multiple mini-interview procedure (HAM-Int) at Hamburg Medical School in August 2019, 189 medical school applicants filled out a questionnaire including the Multidimensional Perfectionism Scale by Hewitt and Flett (MPS-H), the Multidimensional Perfectionism Scale by Frost (MPS-F), the Tolerance for Ambiguity Scale (TAS), the 16-Need for Cognitive Closure Scale (16-NCCS), and sociodemographic data. After the final admission decision, the scores of need for cognitive closure, tolerance for ambiguity, and perfectionism of admitted and rejected applicants were compared. We also assessed the predictive power of need for cognitive closure and age for the admission decision in a binary logistic regression model.

RESULTS

Compared to the admitted applicants, the rejected applicants showed a significantly higher need for cognitive closure (p = .009). A high need for cognitive closure correlated significantly positively with maladaptive perfectionism (p < .001) and significantly negatively with tolerance for ambiguity (p < .001). Low need for cognitive closure and older age were associated with a positive admission decision.

CONCLUSIONS

Regarding the personality traits need for cognitive closure, tolerance for ambiguity, and perfectionism we identified interesting differences and correlations of relevance for physicians' daily work in medical school applicants who were admitted or rejected after participating in a multiple mini-interview selection procedure. Further studies are needed to investigate these characteristics and their development longitudinally in medical students and to correlate them with students' medical performance.

Early Years Research Elective: Changing Perspectives and Dealing with Uncertainty

Uncertainty is ever-present within the medical profession. To effectively manage uncertainty, future doctors must develop key competencies including resilience, creativity and adaptability along with the capacity for collaboration and embracing multiculturalism. The authors believe that attending an overseas clinical research placement as a junior medical student can benefit medical education by offering an early opportunity to develop these qualities. These views are supported by reflections on a clinical research module and placement in Guangzhou, China completed by the authors during the second year of medical school and aims to highlight key learning opportunities.