Article

Tolerance for Ambiguity: An Ethics-Based Criterion for Medical Student Selection

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Abstract

Planned changes to the MCAT exam and the premedical course requirements are intended to enable the assessment of humanistic characteristics and, thus, to select students who are more likely to become physicians who can communicate and relate with patients and engage in ethical decision making. Identifying students who possess humanistic and communication skills is an important goal, but the changes being implemented may not be sufficient to evaluate key personality traits that characterize well-rounded, thoughtful, empathic, and respectful physicians.The author argues that consideration should be given to assessing prospective students' tolerance for ambiguity as part of the admission process. Several strategies are proposed for implementing and evaluating such an assessment. Also included in this paper is an overview of the conceptual and empirical literature on tolerance for ambiguity among physicians and medical students, its impact on patient care, and the attention it is given in medical education. This evidence suggests that if medical schools admitted students who possess a high tolerance for ambiguity, quality of care in ambiguous conditions might improve, imbalances in physician supply and practice patterns might be reduced, the humility necessary for moral character formation might be enhanced, and the increasing ambiguity in medical practice might be better acknowledged and accepted.

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... Research in physicians has linked poor ambiguity tolerance to a number of factors influencing patient care 16 . Examples include increased ordering of tests 17 , increased patient charges 18 , a tendency to engage in defensive practice 17 , worse attitudes towards underserved populations 19 and experience of discomfort in the context of death and grief 20 . ...
... There is ongoing debate on the extent to which ToA should be considered a stable personality trait or whether it is in fact a malleable attitude 16,[28][29][30][31] . This is important because there is debate over whether ToA should be one of the selection criteria to the health professions, or whether educators should instead focus on training and support for students to cope with ambiguous situations and feelings of uncertainty. ...
... At this stage in the scale development process, the most significant consequence is the time taken to complete the measure which, at only 27 items long, is likely to have minimal adverse impact on participants. Although the use of similar scales has been proposed for the purposes of student selection in other professional groups 16 , we believe that this suggestion should be treated with caution, particularly as there is limited collective understanding of the theoretical basis or potential consequences of doing so. Use of the TAVS scale in further research will allow relevant evidence to be developed in the Veterinary context. ...
Article
The ability to cope with ambiguity and feelings of uncertainty is an essential part of professional practice. Research with physicians has identified that intolerance of ambiguity or uncertainty is linked to stress, and some authors have hypothesized that there could be an association between intolerance of ambiguity and burnout. We describe the adaptation of the TAMSAD (Tolerance of Ambiguity in Medical Students and Doctors) scale for use with veterinary students. Exploratory factor analysis supports a uni-dimensional structure for the Ambiguity tolerance construct. Although internal reliability of the 29-item TAMSAD scale is reasonable (a = .50), an alternative 27-item scale (drawn from the original 41 items used to develop TAMSAD) shows higher internal reliability for veterinary students (a = .67). We conclude that there is good evidence to support the validity of this latter TAVS (Tolerance of Ambiguity in Veterinary Students) scale to study ambiguity tolerance in veterinary students.
... Ambiguity can occur in situations that fluctuate or have unpredictable dynamics (McLain et al., 2015), if situational aspects are perceived as uncertain (Frenkel-Brunswik, 1949;Norton, 1975) and when there are unknown implications to solutions (Clydesdale & Tan, 2009). Specifically, literature suggests when there is no ability for exactness during clinical evaluation, clinical decisions are made based on considerations of probabilities, and prediction of risks are used to inform judgments (Camerer & Weber, 1992;Ellsberg, 1961;Geller, 2013;Geller et al., 1993;Hamilton et al., 2013;Kahn & Sarin, 1988). In nursing, Ironside et al. (2009) emphasized these dynamic aspects of ambiguity during a mock simulation in which a nursing student's performance was evaluated when exposed to multiple patients, during episodes of competing demands, and while situational elements were changing to purposefully shift the clinical priority. ...
... In contrast, intolerance of uncertainty is related to probability and outcomes, suggesting a future orientation (Grenier et al., 2005). Clings to the familiar (Frenkel-Brunswik, 1949) Use of dichotomies/ demarcation lines (Frenkel-Brunswik, 1951) Fear of making mistakes (Geller, 2013) Seeks black/white solutions (Frenkel-Brunswik, 1949) Initiates search for cues/ information seeking (Lurie, 2011;Swoboda, 2008;Taylor, 2000) Suppression (Budner, 1962;McLain, 2009) May neglect reality if opposes assumption (Frenkel-Brunswik, 1949) Initiates reflective reasoning; clinical reasoning and use of intuition (Clydesdale & Tan, 2009;Mamede et al., 2007) Altered comfort levels with open-ended situations (Taylor, 2000) Increased test ordering, defensive practice, or medical error (Davis et al., 2000;Geller, 2013;Swoboda, 2008) Trouble with simultaneously differing/conflicting features; need to dichotomize to reach certainty (Frenkel-Brunswik, 1951) Feelings of uncertainty (Davis et al., 2000;Hamilton et al., 2013;Hancock, Roberts, Monrouxe, & Mattick, 2015) Avoidance/delay (Budner, 1962;Han et al., 2011;McLain, 2009) Premature closure/ conclusion before adequate sampling (Frenkel-Brunswik, 1949;Seaburn et al., 2004;Taylor, 2000) Anxiety/worry (Budner, 1962;Davis et al., 2000;Lally & Cantillon, 2014) Uses oversimplified or overgeneralized approach for a solution (Frenkel-Brunswik, 1949, 1951 Reluctant to think in possibilities; seeks safe and definite route (Frenkel-Brunswik, 1949) Feeling of threat (Budner, 1962;Norton, 1975) Omits facts or ignore cues that don't fit preconceived ideas (Frenkel-Brunswik, 1949) Stress (Budner, 1962;McLain, 2009) Explore symptoms in detail; leads to delay in response (Seaburn et al., 2004) May integrate or become distracted by overlapping stimuli (Loomis & Moskowitz, 1958) Psychological discomfort (Murphy, 2000;Norton, 1975) Inaccessible to new experiences (Frenkel-Brunswik, 1950, 1951 Preference for concreteness (Clydesdale & Tan, 2009;Frenkel-Brunswik, 1951;Murphy, 2000;Taylor, 2000) Denial (Budner, 1962;McLain, 2009;Taylor, 2000) (Continued) Probability judgments and choices are made (Clydesdale & Tan, 2009;Einhorn and Hogarth, 1985;Kahn & Sarin, 1988;Seaburn et al., 2004). ...
... In contrast, intolerance of uncertainty is related to probability and outcomes, suggesting a future orientation (Grenier et al., 2005). Clings to the familiar (Frenkel-Brunswik, 1949) Use of dichotomies/ demarcation lines (Frenkel-Brunswik, 1951) Fear of making mistakes (Geller, 2013) Seeks black/white solutions (Frenkel-Brunswik, 1949) Initiates search for cues/ information seeking (Lurie, 2011;Swoboda, 2008;Taylor, 2000) Suppression (Budner, 1962;McLain, 2009) May neglect reality if opposes assumption (Frenkel-Brunswik, 1949) Initiates reflective reasoning; clinical reasoning and use of intuition (Clydesdale & Tan, 2009;Mamede et al., 2007) Altered comfort levels with open-ended situations (Taylor, 2000) Increased test ordering, defensive practice, or medical error (Davis et al., 2000;Geller, 2013;Swoboda, 2008) Trouble with simultaneously differing/conflicting features; need to dichotomize to reach certainty (Frenkel-Brunswik, 1951) Feelings of uncertainty (Davis et al., 2000;Hamilton et al., 2013;Hancock, Roberts, Monrouxe, & Mattick, 2015) Avoidance/delay (Budner, 1962;Han et al., 2011;McLain, 2009) Premature closure/ conclusion before adequate sampling (Frenkel-Brunswik, 1949;Seaburn et al., 2004;Taylor, 2000) Anxiety/worry (Budner, 1962;Davis et al., 2000;Lally & Cantillon, 2014) Uses oversimplified or overgeneralized approach for a solution (Frenkel-Brunswik, 1949, 1951 Reluctant to think in possibilities; seeks safe and definite route (Frenkel-Brunswik, 1949) Feeling of threat (Budner, 1962;Norton, 1975) Omits facts or ignore cues that don't fit preconceived ideas (Frenkel-Brunswik, 1949) Stress (Budner, 1962;McLain, 2009) Explore symptoms in detail; leads to delay in response (Seaburn et al., 2004) May integrate or become distracted by overlapping stimuli (Loomis & Moskowitz, 1958) Psychological discomfort (Murphy, 2000;Norton, 1975) Inaccessible to new experiences (Frenkel-Brunswik, 1950, 1951 Preference for concreteness (Clydesdale & Tan, 2009;Frenkel-Brunswik, 1951;Murphy, 2000;Taylor, 2000) Denial (Budner, 1962;McLain, 2009;Taylor, 2000) (Continued) Probability judgments and choices are made (Clydesdale & Tan, 2009;Einhorn and Hogarth, 1985;Kahn & Sarin, 1988;Seaburn et al., 2004). ...
Article
Purpose: To analyze the concept of ambiguity in a nursing context. Background: Ambiguity is inherent within nursing practice. As health care becomes increasingly complex, nurses must continue to successfully deal with greater amounts of clinical ambiguity. Although ambiguity is discussed in nursing, minimal concept refinement exists to capture the contextual intricacies from a nursing lens. Nurse perception of an ambiguous clinical event, in combination with nurse tolerance level for ambiguity, can impact nurse response. Yet, little is known about what constitutes ambiguity within nursing practice (AWNP). Method: Rodgers evolutionary method was used to explore AWNP, with emphasis on nurse thinking during ambiguous clinical situations. Literature searches across multiple databases yielded 38 articles for analysis. Results: Attributes of AWNP include (a) variations in cues/available information, (b) multiple interpretations, (c) novel/nonroutine presentations, and (d) unpredictable. Antecedents include (a) a context-specific, clinical situation with ambiguous features needing evaluation and (b) an individual to sense a knowledge gap or perceive ambiguity. Consequences include ranges of (a) emotional, (b) behavioral, and (c) cognitive clinician responses. Conclusion: Preliminary findings support AWNP as a distinct concept in which ambiguity perceived by the nurse likely affects judgment, decision making, and clinical interventions. AWNP is a clinically relevant concept requiring continued development.
... 3,4 Several publications have associated intolerance of uncertainty with increased rates of anxiety and burnout, failure to adhere to evidence-based guidelines, fear of litigation, and difficult doctorpatient relationships. 5,6 By contrast, a high tolerance for uncertainty has been associated with greater leadership abilities. 7 For these reasons, extensive research into whether future physicians' responses to uncertainty may be conditioned has been carried out in an attempt to mitigate or remove some of the negative impacts that an intolerance for clinical uncertainty may have. ...
... By contrast, a negative feedback loop may exist for students who are intolerant of uncertainty, whereby they actively avoid uncertainty and become less tolerant of uncertain situations. 6 Theoretically, learning interventions in medical school may help to support the development of students most intolerant to uncertain situations. Indeed, there is a growing body of evidence to suggest that ambiguity and uncertainty should be more prominent features of a medical education curriculum, 8 with some calling for the assessment of tolerance towards uncertainty in medical school applicants during the admission process. ...
... Indeed, there is a growing body of evidence to suggest that ambiguity and uncertainty should be more prominent features of a medical education curriculum, 8 with some calling for the assessment of tolerance towards uncertainty in medical school applicants during the admission process. 6 Teaching a constructive response towards uncertainty may decrease the likelihood of anxiety and burnout and may help to reduce maladaptive responses. Luther and Crandall write: '. . ...
... I have chosen Sweek's definition of professional attributes, because first, medical students' reflectivity, moral reasoning, responsiveness to societal needs, empathy, tolerance of uncertainty, have been subject of repeated past studies. Second, there is evidence that moral reasoning is associated with fewer malpractice claims ; intolerance of uncertainty-with physicians' authoritarianism, dogmatism, rigidity, conformity, and ethnic prejudice (Geller 2013;Wayne et al. 2011); emotional intelligence-with improved doctor-patient relationship, teamwork, communication skills and stress management (Arora et al. 2010) and empathy-with academic performance, clinical competence, and with patients' compliance, satisfaction and quality of life (Hojat et al. 2002;Neumann et al. 2011). ...
... Uncertainty was rejected in dualism, viewed as temporary in multiplicity, accepted as legitimate during relativism, and dealt with when students affirm themselves in their commitments. Tolerance of uncertainty has been mostly measured by self-administered instruments (Geller 2013;Wayne et al. 2011;Weissenstein et al. 2014;Hancock et al. 2015). ...
... Studies of tolerance of uncertainty have detected a higher tolerance of uncertainty in students who were older at entry into medical school and in older physicians; however, they did not detect significant differences between junior and senior medical students (Wayne et al. 2011;Geller 2013;Weissenstein et al. 2014;Hancock et al. 2015). Similarly, there were no differences in emotional intelligence scores between junior and senior medical students (Stratton et al. 2008;Chew et al. 2013). ...
Article
Full-text available
Undergraduate clinical education follows the “bedside” tradition that exposes students to inpatients. However, the hospital learning environment has two main limitations. First, most inpatients require acute care, and students may complete their training without seeing patients with frequent non-emergent and chronic diseases that are managed in outpatient settings. Second, students rarely cope with diagnostic problems, because most inpatients are diagnosed in the community or the emergency room. These limitations have led some medical schools to offer longitudinal integrated clerkships in community settings instead of hospital block clerkship rotations. In this paper, I propose the hypothesis that the hospital learning environment has a third limitation: it causes students’ distress and delays their development of reflectivity and medical professionalism. This hypothesis is supported by evidence that (a) the clinical learning environment, rather than students’ personality traits, is the major driver of students’ distress, and (b) the development of attributes, such as moral reasoning, empathy, emotional intelligence and tolerance of uncertainty that are included in the definitions of both reflectivity and medical professionalism, is arrested during undergraduate medical training. Future research may test the proposed hypothesis by comparing students’ development of these attributes during clerkships in hospital wards with that during longitudinal clerkships in community settings.
... The participants received the lowest scores for the facet of competence "Structure, work planning and priorities" [6], while at the same time they felt the highest strain during the management phase of the assessment with interprofessional interactions where this competence is especially important [7]. Of particular importance for medical practice are the mastery of clinical reasoning and problem solving [8], coping with uncertainty, which is already a criterion used in the selection of medical students [9], and the development of a blame-free medical culture [10]. Within this context there are good starting points for additional strategic developments of medical curricula with a greater emphasis on practice. ...
... In der Ausprägung der Kompetenzfacette "Struktur, Arbeitsplanung und Dringlichkeit" erhielten die Teilnehmenden die niedrigsten Bewertungen [6], während sie sich gleichzeitig in der Managementphase des Assessments mit interprofessionellen Interaktionen, wo diese Kompetenzfacette besonders wichtig ist, am stärksten beansprucht fühlten [7]. Besonders bedeutsam für die ärztliche Praxis sind in der Zusammenführung der Kompetenzen das Erlernen des klinischen Argumentierens [8], der Umgang mit Unsicherheit, der bereits als Kriterium in Auswahlverfahren für Medizinstudierende eingesetzt wurde [9], und die Entwicklung einer schuldzuweisungsfreien medizinischen Arbeitskultur [10]. Vor diesem Hintergrund bieten sich gute Ansatzpunkte zu weiteren strategischen Entwicklungen medizinischer Curricula mit größerer Praxisnähe. ...
... Professionals with a high tolerance for uncertainty perceive ambiguous scenarios as desirable or intellectually stimulating (Herman et al. 2010). Health care is full of uncertainties and practitioners who perceive them as opportunities to grow can enhance their tolerance further (Geller 2013;Hancock et al. 2015). Those who are intolerant tend to avoid ambiguous stimuli, further undermining their ambiguity-processing capacity (Geller 2013;Hancock et al. 2015). ...
... Health care is full of uncertainties and practitioners who perceive them as opportunities to grow can enhance their tolerance further (Geller 2013;Hancock et al. 2015). Those who are intolerant tend to avoid ambiguous stimuli, further undermining their ambiguity-processing capacity (Geller 2013;Hancock et al. 2015). Highreliability organizations promote resilience by enhancing employees' capacity to manage uncertainty (Weick and Sutcliffe 2015). ...
Article
Full-text available
Objective To investigate the factors associated with resilience among medical professionals. Data Sources/Study Setting. Administrative information from a rural health care network (1 academic medical center, 6 hospitals, 31 clinics, and 20 school health centers) was triangulated with self-report data from 308 respondents (response rate=65.1 percent) to a 9/2013-1/2014 survey among practitioners serving a nine-county 5,600-square-mile area. Study Design. A cross-sectional questionnaire survey comprising valid measures of resilience, practice meaningfulness, satisfaction, and risk/uncertainty intolerance, nested within a prospective, community-based project. Data Collection/Extraction Methods. The sampling frame included practitioners on institutional payroll, excluding voluntary/involuntary attritions and advisory board/research team members. In multivariable mixed-effects models, we regressed full-range and high-/low-resilience scores on demographics, professional satisfaction, workplace needs, risk/uncertainty intolerance, and service unit characteristics. Principal Findings. Relational needs, uncertainty intolerance, satisfaction 75 percent of the time, number of practitioners on a unit, and workload were significantly associated with resilience. Higher scores were most strongly associated with uncertainty tolerance, satisfaction, and practitioner numbers. Practitioner/unit demographics were mostly nonsignificant. Conclusions. More resilient practitioners experienced frequent satisfaction, relational needs gratification, better uncertainty tolerance, lighter workloads, and practiced on units with more colleagues. Further studies should investigate well-being interventions based on these mutable factors.
... Those practitioners who tolerate uncertainty well find cognitively ambiguous clinical scenarios intellectually stimulating [118]. Since such uncertainties are commonplace in medical practice, those who see them as opportunities to grow can build their tolerance further [119,120], enhancing the quality of their work life. Those who are intolerant of uncertainty seek to avoid ambiguous stimuli, which further degrades their ambiguity-processing capacity [119,120], and undermines their professional satisfaction. ...
... Since such uncertainties are commonplace in medical practice, those who see them as opportunities to grow can build their tolerance further [119,120], enhancing the quality of their work life. Those who are intolerant of uncertainty seek to avoid ambiguous stimuli, which further degrades their ambiguity-processing capacity [119,120], and undermines their professional satisfaction. ...
Article
Full-text available
Background: Widespread dissatisfaction among United States (U.S.) clinicians could endanger ongoing reforms. Practitioners in rural/underserved areas withstand stressors that are unique to or accentuated in those settings. Medical professionals employed by integrating delivery systems are often distressed by the cacophony of organizational change(s) that such consolidation portends. We investigated the factors associated with dis/satisfaction with rural practice among doctors/non-physician practitioners employed by an integrated healthcare delivery network serving 9 counties of upstate New York, during a time of organizational transition. Methods: We linked administrative data about practice units with cross-sectional data from a self-administered multi-dimensional questionnaire that contained practitioner demographics plus valid scales assessing autonomy/relatedness needs, risk aversion, tolerance for uncertainty/ambiguity, meaningfulness of patient care, and workload. We targeted medical professionals on the institutional payroll for inclusion. We excluded those who retired, resigned or were fired during the study launch, plus members of the advisory board and research team. Fixed-effects beta regressions were performed to test univariate associations between each factor and the percent of time a provider was dis/satisfied. Factors that manifested significant fixed effects were entered into multivariate, inflated beta regression models of the proportion of time that practitioners were dis/satisfied, incorporating clustering by practice unit as a random effect. Results: Of the 473 eligible participants. 308 (65.1 %) completed the questionnaire. 59.1 % of respondents were doctoral-level; 40.9 % mid-level practitioners. Practitioners with heavier workloads and/or greater uncertainty intolerance were less likely to enjoy top-quintile satisfaction; those deriving greater meaning from practice were more likely. Higher meaningfulness and gratified relational needs increased one's likelihood of being in the lowest quintile of dissatisfaction; heavier workload and greater intolerance of uncertainty reduced that likelihood. Practitioner demographics and most practice unit characteristics did not manifest any independent effect. Conclusions: Mutable factors, such as workload, work meaningfulness, relational needs, uncertainty/ambiguity tolerance, and risk-taking attitudes displayed the strongest association with practitioner satisfaction/dissatisfaction, independent of demographics and practice unit characteristics. Organizational efforts should be dedicated to a redesign of group-employment models, including more equitable division of clinical labor, building supportive peer networks, and uncertainty/risk tolerance coaching, to improve the quality of work life among rural practitioners.
... This situational uncertainty requires physicians the ability to properly react to it [8]. Literature consistently indicates that the capacity to tolerate and manage ambiguity and uncertainty represents a fundamental competence for physicians [2,[9][10][11]. In health care, a number of studies found some correlations between physicians' individual ability to tolerate ambiguity and their level of psychological well-being. In particular, physicians with low tolerance of ambiguity and uncertainty tend to report higher rate of referrals, burnout, and anxiety and lower level of satisfaction [10,12], less comfort in dealing with dying patients, and higher levels of dogmatism, rigidity, and conformism [13,14]. ...
... Literature is quite relevant and rich [11] if we focus on the conceptual and theoretical issues associated with ambiguity and uncertainty tolerance, whereas little empirical research has been conducted on this topic. More precisely, the few empirical studies mainly involved medical students or registrars who were still in training [10,27,28]. ...
Article
Full-text available
Medical practice is inherently ambiguous and uncertain. The physicians’ ability to tolerate ambiguity and uncertainty has been proved to have a great impact on clinical practice. The primary aim of the present study was to test the hypothesis that higher degree of physicians’ ambiguity and uncertainty intolerance and higher need for cognitive closure will predict higher work stress. Two hundred and twelve physicians (mean age = 42.94 years; SD = 10.72) from different medical specialties with different levels of expertise were administered a set of questionnaires measuring perceived levels of work-related stress, individual ability to tolerate ambiguity, stress deriving from uncertainty, and personal need for cognitive closure. A linear regression analysis was performed to examine which variables predict the perceived level of stress. The regression model was statistically significant [R² = .32; F(10,206) = 8.78, p ≤ .001], thus showing that, after controlling for gender and medical specialty, ambiguity and uncertainty tolerance, decisiveness (a dimension included in need for closure), and the years of practice were significant predictors of perceived work-related stress. Findings from the present study have some implications for medical education. Given the great impact that the individual ability to tolerate ambiguity and uncertainty has on the physicians’ level of perceived work-related stress, it would be worth paying particular attention to such a skill in medical education settings. It would be crucial to introduce or to empower educational tools and strategies that could increase medical students’ ability to tolerate ambiguity and uncertainty. Abbreviations: JSQ: Job stress questionnaire; NFCS: Need for cognitive closure scale; PRU: Physicians’ reactions to uncertainty; TFA: Tolerance for ambiguity
... Conversely, students with a low tolerance for ambiguity at medical school admission would decrease tolerance even more, until the end of their careers (negative feedback). 11 This evidence suggests that if medical schools selected candidates who show a high tolerance for ambiguity, quality of care in complex and ambiguous clinical scenarios might improve. 9 Concurrently, other researchers demonstrated that medical students who were more intolerant of ambiguity experienced negative attitudes toward alcoholic patients, 12 and also towards the poor and underserved. ...
... Conversely, specialties that are inherently ambiguous, such as psychiatry, appealed to individuals with higher tolerance. 11,12 Traditionally, only a few studies have clearly distinguished among the different kinds of uncertainties, as risk, complexity, and ambiguity; 2,11 therefore, this lack of conceptual and assessment specificity may have accounted for inconsistent findings in most past research analyses. ...
Article
Full-text available
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.
... It could also guide research on the effects of different uncertainty management strategies on not only patient-centered but also physician-centered outcomes, including well-being and burnout. 26,[52][53][54] At the same time, the taxonomy might also enable clinicians and educators to manage uncertainty in a more intentional, systematic, and rational manner. Applied as a tool for clinical practice or training, it could help physicians take inventory of alternative management strategies and select the most appropriate strategy based on various factors, for example, the particular diagnosis (i.e., source and issue) of the uncertainty at hand as well as its prognosis (i.e., reducibility). 1 It could help make the process of uncertainty management more active, intentional, and deliberative rather than passive, organic, and driven primarily by the ''hidden curriculum'' of medical care and training. ...
... In reflecting on the evolution of their own uncertainty tolerance, participants identified epistemic maturity, humility, flexibility, and openness as acquired capacities that helped them to tolerate uncertainty-that is, to palliate its negative effects and realize its positive ones. These capacities may thus represent key components of uncertainty tolerance and instrumental goals in managing medical uncertainty ( Figure 2); however, more research is needed to determine whether they can be intentionally cultivated 52,55 and to identify other important normative goals. ...
Article
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Background: Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. Objectives: To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians' tolerance of medical uncertainty. Design: Qualitative study using individual in-depth interviews. Participants: Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1-3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine-pediatrics), at a single large US teaching hospital. Measurements: Semistructured interviews explored participants' strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. Results: Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. Conclusions: Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.
... 1998; Luther and Crandall 2011;Simpkin and Schwartzstein 2016). Thus, health professions educators often express concerns that students struggle with ambiguity and uncertainty (Fargason et al. 1997;Luther and Crandall 2011;White and Williams 2017), and instead strive to impose certainty on inherently ambiguous situations (Geller 2013;Lingard et al. 2003;Simpkin and Schwartzstein 2016). As a result, there are ongoing calls to help learners develop "positive" responses to uncertainty and ambiguity (White and Williams 2017). ...
... The term 'uncertainty,' as applied to ill-defined problems in medicine, is frequently used in ways that do not sufficiently distinguish between the properties of the situation and the 'lived experience' 1 of the individual (Atkinson 1984;Babrow et al. 1998;Djulbegovic et al. 2011;Fox 1957;Lazarus 1991;Lazarus and Folkman 1984;Light 1979;Lipshitz and Strauss 1997;Mishel 1988Mishel , 1990Schraw et al. 1995;Schwartz and Griffin 1986;Simpkin and Schwartzstein 2016;Simpson et al. 1986). In fact, the term 'uncertainty' is often used interchangeably with the term 'ambiguity' (Geller 2013;White and Williams 2017). To draw this important distinction between the situation and the lived experience more explicitly, we propose using 'ambiguity' to represent the properties of the situation and 'uncertainty' to represent the lived experience of an individual. ...
Article
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Learning to take safe and effective action in complex settings rife with uncertainty is essential for patient safety and quality care. Doing so is not easy for trainees, as they often consider certainty to be a necessary precursor for action and subsequently struggle in these settings. Understanding how skillful clinicians work comfortably when uncertain, therefore, offers an important opportunity to facilitate trainees’ clinical reasoning development. This critical review aims to define and elaborate the concept of ‘comfort with uncertainty’ in clinical settings by juxtaposing a variety of frameworks and theories in ways that generate more deliberate ways of thinking about, and researching, this phenomenon. We used Google Scholar to identify theoretical concepts and findings relevant to the topics of ‘uncertainty,’ ‘ambiguity,’ ‘comfort,’ and ‘confidence,’ and then used preliminary findings to pursue parallel searches within the social cognition, cognition, sociology, sociocultural, philosophy of medicine, and medical education literatures. We treat uncertainty as representing the lived experience of individuals, reflecting the lack of confidence one feels that he/she has an incomplete mental representation of a particular problem. Comfort, in contrast, references confidence in one’s capabilities to act (or not act) in a safe and effective manner given the situation. Clinicians’ ‘comfort with uncertainty’ is informed by a variety of perceptual, emotional, and situational cues, and is enabled through a combination of self-monitoring and forward planning. Potential implications of using ‘comfort with uncertainty’ as a framework for educational and research programs are explored.
... Intolerance of ambiguity and uncertainty among clinicians is associated with increased resource use and poor communication skills. 3 Medical students' intolerance of uncertainty has also been associated with higher levels of psychological distress. 4 Concern that failing to teach students to better deal with uncertainty might ultimately increase the likelihood of disillusionment and burnout has led to calls for increased attention to ambiguity and uncertainty within the medical school curriculum. ...
Article
Conveying the uncertainty inherent in clinical practice has rightly become a focus of medical training. To date, much of the emphasis aims to encourage trainees to acknowledge and accept uncertainty. Intolerance of uncertainty is associated with medical student distress and a tendency in clinicians toward overtreatment. The authors argue that a deeper, philosophical understanding of the nature of uncertainty would allow students and clinicians to move beyond simple acceptance to explicating and mitigating uncertainty in practice.Uncertainty in clinical medicine can be categorized philosophically as moral, metaphysical, and epistemic uncertainty. Philosophers of medicine-in a way analogous to ethicists a half-century ago-can be brought into medical education and medical practice to help students and physicians explore the epistemic and metaphysical roots of clinical uncertainty. Such an approach does not require medical students to master philosophy and should not involve adding new course work to an already crowded medical curriculum. Rather, the goal is to provide students with the language and reasoning skills to recognize, evaluate, and mitigate uncertainty as it arises. The authors suggest ways in which philosophical concepts can be introduced in a practical fashion into a variety of currently existing educational formats. Bringing the philosophy of medicine into medical education not only promises to improve the training of physicians, but ultimately lead to more mindful clinical practice, to the benefit of physicians and patients alike.
... This allows us to respond mindfully and choose more functional rather than dysfunctional ways to deal with uncertainty (Danczak and Lea 2014). Indeed, evidence suggests modifying our reaction to uncertainty is possible with practice (Geller 2013). ...
Article
Background: Effectively managing clinical uncertainty is increasingly recognized as a goal of medical education. Stress from uncertainty has been associated with depression and burnout in trainees and may also impact patient care. Despite its importance, however, strategies to embrace uncertainty in clinical practice are lacking. Aims: The literature on uncertainty in medicine was reviewed. Incorporating insights from faculty and students, 12 tips for healthcare educators to help themselves and others thrive in the face of clinical uncertainty were developed. Results: Educators will find the tips practical and easy to implement in their day-to-day interactions as clinicians and teachers. Tips are divided into tips for oneself; for implementing with students and trainees; and for implementing with patients and in healthcare systems. Conclusions: These tips can enhance healthcare professionals’ and students’ ability to thrive in the face of uncertainty. Strategies to embrace uncertainty are critical for ourselves, our trainees, our patients, and our healthcare systems.
... Knowledge can be drawn from the included studies; while measures of anger, altruism, compassion to others, coping, empathy, life satisfaction, quality of life, self-efficacy, self-esteem, and spirituality were extracted, there were too few studies to warrant separate analysis. We may also recommend exploring measures related to qualities and skills often considered desirable in professionals (e.g., ambiguity tolerance, emotional intelligence, empathy, humility, leadership, resilience) [83][84][85][86][87] as well as utilizing behavioral measures to assess impact on important clinical skills (e.g., diagnostic accuracy). Furthermore, exploration of the interpersonal impacts of mindfulness training may be of value. ...
Article
Objective: Healthcare professionals (HCPs) experience a wide range of physical and psychological symptoms that can affect quality of patient care. Previous meta-analyses exploring mindfulness-based interventions (MBIs) for HCPs have been limited by their narrow scope regarding intervention type, target population, and/or measures, and reliance on uncontrolled studies; therefore, a more comprehensive and methodologically rigorous examination is warranted. This meta-analysis quantified the effectiveness of MBIs on distress, well-being, physical health, and performance in HCPs and HCPs-in-training. Method: RCTs examining the effect of meditation and MBIs on HCPs and HCPs-in-training were identified and reviewed. Two independent reviewers extracted data and assessed risk of bias. Results: Thirty-eight studies were included in the analyses (n = 2505; 75.88% female). Intervention had a significant moderate effect on anxiety (Hedge's g = 0.47), depression (Hedge's g = 0.41), psychological distress (Hedge's g = 0.46), and stress (Hedge's g = 0.52). Small to moderate effects were also found for burnout (Hedge's g = 0.26) and well-being at post-intervention (Hedge's g = 0.32). Effects were not significant for physical health and performance. Larger intervention effects on overall outcomes were found with HCPs (Hedge's g = 0.52), with Mindfulness-based Stress Reduction intervention (Hedge's g = 0.47), and inactive controls (Hedge's g = 0.36). Conclusions: Results suggest mindfulness-based interventions are effective in reducing distress and improving well-being in HCPs and HCP-ITs. Subgroup analyses suggest the importance of exploring potential participants' needs prior to selecting the type of mindfulness intervention. Future studies should assess changes in mindfulness and include active controls.
... It is possible to select for personal qualities which could assist in managing such challenges, but evidence for the reliable prediction of such outcomes is limited. a) Consider selection methods that have been shown to identify qualities appropriate for the challenges of study and training in medicine: While intuitively desirable, the evidence for selecting qualities such as tolerance of ambiguity [26] and the effect on subsequent performance is limited. Understanding of best practice in selection is still evolving [27][28][29]. ...
Article
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Background Medical student wellbeing–a consensus statement from Australia and New Zealand outlines recommendations for optimising medical student wellbeing within medical schools in our region. Worldwide, medical schools have responsibilities to respond to concerns about student psychological, social and physical wellbeing, but guidance for medical schools is limited. To address this gap, this statement clarifies key concepts and issues related to wellbeing and provides recommendations for educational program design to promote both learning and student wellbeing. The recommendations focus on student selection; learning, teaching and assessment; learning environment; and staff development. Examples of educational initiatives from the evidence-base are provided, emphasising proactive and preventive approaches to student wellbeing. Main recommendations The consensus statement provides specific recommendations for medical schools to consider at all stages of program design and implementation. These are:Design curricula that promote peer support and progressive levels of challenge to students. Employ strategies to promote positive outcomes from stress and to help others in need. Design assessment tasks to foster wellbeing as well as learning. Provide mental health promotion and suicide prevention initiatives. Provide physical health promotion initiatives. Ensure safe and health-promoting cultures for learning in on-campus and clinical settings. Train staff on student wellbeing and how to manage wellbeing concerns. Conclusion A broad integrated approach to improving student wellbeing within medical school programs is recommended. Medical schools should work cooperatively with student and trainee groups, and partner with clinical services and other training bodies to foster safe practices and cultures. Initiatives should aim to assist students to develop adaptive responses to stressful situations so that graduates are prepared for the realities of the workplace. Multi-institutional, longitudinal collaborative research in Australia and New Zealand is needed to close critical gaps in the evidence needed by medical schools in our region.
... As traditional science research strives for reproducibility through calculated processes, arts-based methods welcome variations. Art is inherently ambiguous, which is a core characteristic of many experiences in the practice of medicine (Geller 2013). This project places emphasis on the "journey" and the "story," rather than just quantifiable results. ...
Article
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This arts- based project creatively introduces residents to photography, self-portraiture and narratives to document the longitudinal journey of becoming a family physician. Visual arts and writing can foster reflection: an important skill to cultivate in developing physicians. Unfortunately, arts based programs are lacking in many residency programs. Tools and venues that nourish physician well being and resilience may be important in today’s changing healthcare environment and epidemic of physician burnout. Residents created self-portraits with accompanying narratives throughout their three-year training. Analysis of the portraits and accompanying narratives completed the assessment. Residents created a body of work that includes 182 creative and deeply personal portraits and narratives. The five most frequent themes of portraits included “Residency is Difficult,” “Hobbies,” “Family,” “Growing as a Doctor,” and “Coping Mechanisms.” Self-portrait photography and reflection gives insight into the journey of becoming a family medicine physician at a deeply personal and professional level. Further partnerships between residency programs and the arts should be explored to promote reflection.
... 4,5 Given these findings, some schools have integrated tolerance of uncertainty measures into their selection criteria. 6 Self-compassion represents yet another psychological trait that may influence one's clinical practice. Similarly, it can be measured using validated instruments, such as the Self-Compassion Scale. ...
Article
Full-text available
Managing the uncertainty of clinical practice represents a significant source of stress for clinicians, including medical students transitioning into the clinical workplace. Self-compassion, a strategy to better cope with stress and burnout, may represent a skill that can be leveraged to better prepare learners for the uncertainty inherent in clinical practice. A negative correlation between intolerance of uncertainty and self-compassion has been demonstrated in undergraduate students and in the general population. An examination of this relationship in medical students may help inform future curricular development for addressing burnout in undergraduate medical education. We electronically administered the Intolerance of Uncertainty Short Scale and the Self-Compassion Short Form to 273 third-year medical students from a single institution and analyzed data via regression. A significant negative correlation was found between intolerance of uncertainty and self-compassion (p < 0.0001). Students with higher levels of self-compassion showed lower levels of intolerance of uncertainty. This is consistent with findings in other populations. Our findings offer a starting point for designing training experiences that strengthen student self-compassion to enhance their ability to reconcile the uncertainty they will encounter in clinical practice.
... Geller et al. [17] have reported that tolerance to ambiguity does not change throughout medical school and argue that it should be included as one of the qualifications required for admittance to medical school [45]. Meanwhile, some researchers claim that tolerance to uncertainty in medical students may change or improve during medical school, at least in part [6,46]. ...
Article
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In an era of high technology and low trust, acknowledging and coping with uncertainty is more crucial than ever. Medical uncertainty has been considered an innate feature of medicine and medical practice. An intolerance to uncertainty increases physicians' stress and the effects of burnout and may be a potential threat to patient safety. Understanding medical uncertainty and acquiring proper coping strategies has been regarded to be a core clinical competency for medical graduates and trainees. Integrating intuition and logic and creating a culture that acknowledges medical uncertainty could be suggested ways to teach medical uncertainty. In this article, the authors describe the concepts of medical uncertainty, its influences on physicians and on medical students toward medical decision making, the role of tolerance/intolerance to uncertainty, and proposed strategies to improve coping with medical uncertainty.
... In the future, longitudinal, interventional, and experimental research designs are needed to test causal mechanisms-including moderating and mediating variables-linking UT and health-related outcomes, and to elucidate the extent to which UT represents a stable trait or a dynamic state. The working hypothesis of past research is that UT is primarily a stable personality trait; however, there is evidence that UT may be mutable [31,32,82]-which may suggest the possibility of intentionally intervening to increase UT in healthcare or educational settings [83]. ...
Article
Background: Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes. Methods: We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme. Results: Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being. Conclusions: Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.
... Reaction to uncertainty and resilience are dynamic personality states that can be modified, reflecting a complex combination of inherited susceptibility and environmental influences. 12,13 Interdisciplinary studies that involve biosciences as well as behavioral science now strongly support the contribution of genetics to resilience as well as interactions ...
Article
Objectives: Depression and burnout are highly prevalent among residents, but little is known about modifiable personality variables-such as resilience and stress from uncertainty-that may predispose to these conditions. Residents are routinely faced with uncertainty when making medical decisions. We sought to determine how stress from uncertainty is related to resilience among pediatric residents and whether these attributes are associated with depression and burnout. Methods: We surveyed 86 residents in pediatric residency programs from four urban freestanding children's hospitals in North America in 2015. Stress from uncertainty was measured using the Physicians' Reaction to Uncertainty Scale; resilience using the 14-item Resilience Scale; depression using the Harvard National Depression Screening Scale; and burnout using single-item measures of emotional exhaustion and depersonalization from the Maslach Burnout Inventory. Results: 50/86 residents responded to the survey(58.1%). Higher levels of stress from uncertainty were correlated with lower resilience (r=-.60;p<0.001). Five residents(10%) met depression criteria and 15 residents(31%) met criteria for burnout. Depressed residents had higher mean levels of stress due to uncertainty (51.6[9.1] vs. 38.7[6.7];p<0.001) and lower mean levels of resilience (56.6[10.7] vs. 85.4[8.0];p<0.001) compared to residents who were not depressed. Burned out residents also had higher mean levels of stress due to uncertainty (44.0[8.5] vs. 38.3[7.1];p=0.02) and lower mean levels of resilience (76.7[14.8] vs. 85.0[9.77];p=0.02) compared to residents who were not burned out. Conclusions: We found high levels of stress from uncertainty and low levels of resilience were strongly correlated with depression, and burnout. Efforts to enhance tolerance of uncertainty and resilience among residents may provide opportunities to mitigate resident depression and burnout.
... Physicians undoubtedly need skills, knowledge, and technical competence, and yet there are also other personal qualities that undeniably constitute Ba well-rounded doctor. mong these are wisdom, 10 empathy, 11 tolerance for ambiguity, 12 skilled observation, 13 and emotional resilience. 14 In fact, empathy and tolerance for ambiguity are contained within the Accreditation Council for Graduate Medical Education (ACGME) competencies. ...
Article
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Background: Literature, music, theater, and visual arts play an uncertain and limited role in medical education. One of the arguments often advanced in favor of teaching the humanities refers to their capacity to foster traits that not only improve practice, but might also reduce physician burnout-an increasing scourge in today's medicine. Yet, research remains limited. Objective: To test the hypothesis that medical students with higher exposure to the humanities would report higher levels of positive physician qualities (e.g., wisdom, empathy, self-efficacy, emotional appraisal, spatial skills), while reporting lower levels of negative qualities that are detrimental to physician well-being (e.g., intolerance of ambiguity, physical fatigue, emotional exhaustion, and cognitive weariness). Design: An online survey. Participants: All students enrolled at five U.S. medical schools during the 2014-2015 academic year were invited by email to take part in our online survey. Main measures: Students reported their exposure to the humanities (e.g., music, literature, theater, visual arts) and completed rating scales measuring selected personal qualities. Key results: In all, 739/3107 medical students completed the survey (23.8%). Regression analyses revealed that exposure to the humanities was significantly correlated with positive personal qualities, including empathy (p < 0.001), tolerance for ambiguity (p < 0.001), wisdom (p < 0.001), emotional appraisal (p = 0.01), self-efficacy (p = 0.02), and spatial skills (p = 0.02), while it was significantly and inversely correlated with some components of burnout (p = 0.01). Thus, all hypotheses were statistically significant, with effect sizes ranging from 0.2 to 0.59. Conclusions: This study confirms the association between exposure to the humanities and both a higher level of students' positive qualities and a lower level of adverse traits. These findings may carry implications for medical school recruitment and curriculum design. "[Science and humanities are] twin berries on one stem, grievous damage has been done to both in regarding [them]... in any other light than complemental." (William Osler, Br Med J. 1919;2:1-7).
... More work is also needed to better understand the lived experience of uncertainty, and the ways patients and clinicians deal with the vulnerability it entails [83,84]. To what extent particular responses to uncertainty in different situations-that is, an individual's UT-can be improved is also an important research question with direct implications for patient care and medical education [7,8,85]. Finally, more research is needed to better understand how the interactions between patients, clinicians, and other parties-encompassing both the communication of information and the provision of emotional and relational supportinfluence the effects of uncertainty. ...
Article
Objective: To promote a more systematic approach to research on uncertainty in health care, and to explore promising starting points and future directions for this research. Methods: We examine three fundamental aspects of medical uncertainty that a systematic research program should ideally address: its nature, effects, and communication. We summarize key insights from past empirical research and explore existing conceptual models that can help guide future research. Results: A diverse body of past research on medical uncertainty has produced valuable empirical insights and conceptual models that provide useful starting points for future empirical and theoretical work. However, these insights need to be more fully developed and integrated to answer remaining questions about what uncertainty is, how it affects people, and how and why it should be communicated. Conclusion: Uncertainty in health care is an extremely important but incompletely understood phenomenon. Improving our understanding of the many important aspects of uncertainty in health care will require a more systematic program of research based upon shared, integrative conceptual models and active, collaborative engagement of the broader research community. Practice implications: A more systematic approach to investigating uncertainty in health care can help elucidate how the clinical communication of uncertainty might be improved.
... 16,17 Tolerance for ambiguity has even been touted as a possible selection criterion for medical school, with commentators hypothesising that students who begin medical school with a higher tolerance for uncertainty will have greater tolerance for it by the end of medical school through a positive feedback loop. 18 The Physician Response to Uncertainty (PRU) scales were developed to examine the emotional, cognitive and coping behaviours that doctors use in relation to clinical uncertainty. 19 However, despite the acknowledged importance of tolerance of uncertainty and efforts to include it in medical curricula, few studies have examined its associations. ...
Article
Context: Tolerance for ambiguity is essential for optimal learning and professional competence. General practice trainees must be, or must learn to be, adept at managing clinical uncertainty. However, few studies have examined associations of intolerance of uncertainty in this group. Objectives: The aim of this study was to establish levels of tolerance of uncertainty in Australian general practice trainees and associations of uncertainty with demographic, educational and training practice factors. Methods: A cross-sectional analysis was performed on the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing multi-site cohort study. Scores on three of the four independent subscales of the Physicians' Reaction to Uncertainty (PRU) instrument were analysed as outcome variables in linear regression models with trainee and practice factors as independent variables. Results: A total of 594 trainees contributed data on a total of 1209 occasions. Trainees in earlier training terms had higher scores for 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose diagnosis/treatment uncertainty to patients'. Beyond this, findings suggest two distinct sets of associations regarding reaction to uncertainty. Firstly, affective aspects of uncertainty (the 'Anxiety' and 'Concern' subscales) were associated with female gender, less experience in hospital prior to commencing general practice training, and graduation overseas. Secondly, a maladaptive response to uncertainty (the 'Reluctance to disclose' subscale) was associated with urban practice, health qualifications prior to studying medicine, practice in an area of higher socio-economic status, and being Australian-trained. Conclusions: This study has established levels of three measures of trainees' responses to uncertainty and associations with these responses. The current findings suggest differing 'phenotypes' of trainees with high 'affective' responses to uncertainty and those reluctant to disclose uncertainty to patients. More research is needed to examine the relationship between clinical uncertainty and clinical outcomes, temporal changes in tolerance for uncertainty, and strategies that might assist physicians in developing adaptive responses to clinical uncertainty.
... 19,20 What this study does reveal is that even quite subtle changes in the items constituting a scale can produce significant differences in the levels of mean tolerance of ambiguity between the two populations. This is important at a time when there is growing interest in using scales such as these to aid in high-stakes decision making such entry to medical school, 21 and when there are an increasing number of scales from which to choose. ...
Article
Current guidelines suggest that educators in both medical and veterinary professions should do more to ensure that students can tolerate ambiguity. Designing curricula to achieve this requires the ability to measure and understand differences in ambiguity tolerance among and within professional groups. Although scales have been developed to measure tolerance of ambiguity in both medical and veterinary professions, no comparative studies have been reported. We compared the tolerance of ambiguity of medical and veterinary students, hypothesizing that veterinary students would have higher tolerance of ambiguity, given the greater patient diversity and less wellestablished evidence base underpinning practice. We conducted a secondary analysis of questionnaire data from first-to fourth-year medical and veterinary students. Tolerance of ambiguity scores were calculated and compared using the TAMSAD scale (29 items validated for the medical student population), the TAVS scale (27 items validated for the veterinary student population), and a scale comprising the 22 items common to both scales. Using the TAMSAD and TAVS scales, medical students had a significantly higher mean tolerance of ambiguity score than veterinary students (56.1 vs. 54.1, p < .001 and 60.4 vs. 58.5, p = .002, respectively) but no difference was seen when only the 22 shared items were compared (56.1 vs. 57.2, p = .513). The results do not support our hypothesis and highlight that different findings can result when different tools are used. Medical students may have slightly higher tolerance of ambiguity than veterinary students, although this depends on the scale used.
... Furthermore, tolerance of ambiguity is still often characterized as either a personality trait or a phenomenon related to personality traits [39][40][41][42]. In fact, within the context of medical education, it was recently suggested that medical schools frequently ignore the importance of ambiguity tolerance and that therefore they should incorporate ambiguity tolerance measurement(s) as part of the selection process of their candidates [43]. However, an alternative approach to this issue may be offered by suggesting that the discussion of art works, through the application of VTS, may contribute to medical students' tolerance of ambiguity. ...
Article
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Background Comfort with ambiguity, mostly associated with the acceptance of multiple meanings, is a core characteristic of successful clinicians. Yet past studies indicate that medical students and junior physicians feel uncomfortable with ambiguity. Visual Thinking Strategies (VTS) is a pedagogic approach involving discussions of art works and deciphering the different possible meanings entailed in them. However, the contribution of art to the possible enhancement of the tolerance for ambiguity among medical students has not yet been adequately investigated. We aimed to offer a novel perspective on the effect of art, as it is experienced through VTS, on medical students’ tolerance of ambiguity and its possible relation to empathy. Methods Quantitative method utilizing a short survey administered after an interactive VTS session conducted within mandatory medical humanities course for first-year medical students. The intervention consisted of a 90-min session in the form of a combined lecture and interactive discussions about art images. The VTS session and survey were filled by 67 students in two consecutive rounds of first-year students. Results.67% of the respondents thought that the intervention contributed to their acceptance of multiple possible meanings, 52% thought their visual observation ability was enhanced and 34% thought that their ability to feel the sufferings of other was being enhanced. Statistically significant moderate-to-high correlations were found between the contribution to ambiguity tolerance and contribution to empathy (0.528–0.744; p ≤ 0.01). Conclusions Art may contribute especially to the development of medical students’ tolerance of ambiguity, also related to the enhancement of empathy. The potential contribution of visual art works used in VTS to the enhancement of tolerance for ambiguity and empathy is explained based on relevant literature regarding the embeddedness of ambiguity within art works, coupled with reference to John Dewey’s theory of learning. Given the situational nature of the tolerance for ambiguity in this context, VTS provides a path for enhancing ambiguity tolerance that is less conditioned by character traits. Moreover, the modest form of VTS we utilized, not requesting a significant alteration in the pre-clinical curricula, suggests that enhancing the tolerance of ambiguity and empathy among medical students may be particularly feasible.
... In the course of medical training, numerous morally ambiguous or diagnostically perplexing situations arise (Henry 2006). Indeed, it is hypothesized that a high tolerance for ambiguity is a determining factor in students' future practice settings and moral character formation (Geller 2013). A concerning finding of our work, however, is that students felt harboring doubt could lead to burnout and depression. ...
Article
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Purpose: Existing research shows that medical students experience high levels of distress. The purpose of this study was to understand how medical students experience doubt, and how doubt relates to distress. Methods: A mixed-methods study was conducted among first-year students at the Johns Hopkins University School of Medicine in June 2012. Students answered survey questions and participated in focus groups about doubt and other forms of distress. Results: Ninety-four percent (112) of students responded to the survey, with 49% reporting a moderate or high degree of doubt. Compared to those reporting no or low doubt, students with moderate/high doubt were significantly more likely to question their purpose and identity, struggle to cope with doubt, and experience depression and emotional hardening. Twenty-eight percent of students (34/112) participated in focus groups to explore their doubt, and three themes emerged: types of doubt, ways of coping with doubt, and impact of doubt. Conclusions: Doubt is highly prevalent among first-year medical students, affects their identity and purpose, and has positive and negative consequences. Doubt among medical students merits awareness and further study, as it may be an important mediator of students’ emerging identity and sense of well-being.
... In light of evidence that tolerance for uncertainty is highly variable among matriculants to medical school, 1,36,37 there have been calls to consider tolerance for uncertainty in the medical admissions process. 38 Admissions committees may disagree about the necessity or practicality of exploring applicants' reactions to uncertainty; however, they ought to consider whether and how incorporating an exploration of applicants' reactions to uncertainty fits their goals and situation. Where such exploration does take place, applicants' responses should not be evaluated as a condition of admission but as an exercise in self-awareness. ...
Article
Scholars from a range of disciplines including medicine, sociology, psychology, and philosophy have addressed the concepts of ambiguity and uncertainty in medical practice and training. Most of this scholarship has been descriptive, focusing on defining and measuring ambiguity and uncertainty tolerance or tracking clinicians’ responses to ambiguous and uncertain situations. Meanwhile, scholars have neglected some fundamental normative questions: Is tolerance of uncertainty good; if so, to what extent? Using a philosophical approach to these questions, we show that neither tolerance nor intolerance of uncertainty is necessarily a good or bad trait. Rather, both tolerance and intolerance of uncertainty can give physicians advantages while at the same time exposing them to pitfalls in clinical practice. After making this case, we argue that cultivating certain virtues—like courage, diligence, and curiosity—could help clinicians avoid the dangers of excessive tolerance and intolerance of uncertainty. Finally, we suggest that medical educators develop curricula and career counseling beginning with matriculation and proceeding through specialty choice and residency training that explicitly address trainees’ responses to clinical uncertainty. These programs should encourage trainees, students and residents, to be mindful of their reactions to uncertainty and help them develop virtues that will allow them to avoid the hazards of extreme tolerance or intolerance of uncertainty.
... In turn, students who have difficulty regulating their emotional response to ambiguity may reject or avoid learning. Higher AT is considered desirable in a number of careers in business (Chesley & Wylson, 2016), education (Kajs & McCollum, 2009), medicine (Geller et al., 1990), and psychology (Levitt & Jacques, 2005) with some recommending that AT should be a student selection criterion for post-graduate programs like medicine (Geller, 2013). ...
Article
Full-text available
Facing ambiguity is ubiquitous and perhaps more apparent as the world faces economic, health, and social crises. Ambiguity tolerance (AT) reflects one's ability to manage novel, complex, and insoluble situations and has important implications on learning, intrapersonal behaviour, and decision making. While AT can increase passively over time, there is some research pointing to mindfulness as a method for cultivating AT. Both forms of Western mindfulness (meditative and Langer) positively correlate with AT; however, no study has explored the direct impact of mindfulness induction. 165 undergraduate participants completed baseline measures of AT, trait meditative (MM) and Langer mindfulness (LM), and self-compassion (SC). Participants were randomly assigned to a condition (meditative, Langer, or mind-wandering control) and responded to measures of AT. Measures of state mindfulness were taken pre-post induction to confirm manipulation success and participants provided feedback on the induction tasks. Regression analyses revealed nonreactivity to inner experience (facet of MM), LM, and SC are significantly associated with AT. However, only nonreactivity adds significantly to the variation in AT beyond what is attributable to LM. Repeated measure ANOVAs confirmed state MM and LM were elevated post-induction compared to the control. However, state mindfulness remained enhanced at the experiment's end only for MM and not LM. Participants also reported finding the LM task more difficult than MM but noted greater focus and ability to follow task instructions. No significant effect of induction was found on AT. Future studies could examine how a combination of MM and LM interventions might enhance AT.
... No publications address this issue, but in emergency medicine, it has been suggested that intolerance of uncertainty and ambiguity, particularly regarding outcome of treatment, is associated with practitioner anxiety and burnout, and reluctance to admit uncertainty and mistakes to patients and other practitioners, which suggests suboptimal communication (Kuhn et al., 2009). In general medical practice, low tolerance for ambiguity has also been associated with a biomedical rather than a biopsychosocial worldview of the practitioner, and failure to comply with evidence-based guidelines (Geller, 2013). In contrast, high tolerance for ambiguity in dual-degree students (Doctor of Medicine and Master of Business Administration) was associated with superior leadership abilities (Sherrill, 2001). ...
Article
In many clinical cases a dentist may feel certain when for example diagnosing, deciding on treatment, or assessing the prognosis – in other cases many dentists may feel a degree of doubt or uncertainty. This paper aims to explore the philosophical concept of uncertainty and its different dimensions, using the condition “persistent apical periodontitis associated with a previously root filled tooth” as an example. Acknowledging that uncertainty exists in any clinical situation can be perceived as uncomfortable, as some might regard it as a weakness. While some types of uncertainty met in dental practice can be addressed and reduced, there are other types which are inevitable and must be accepted. To make sound decisions, it is pertinent that the dentist reflects on and values the consequences of uncertainty. In this paper, a conceptual model is presented by which the dentist can identify the type of uncertainty in a clinical case, making it possible to decide on a strategy on how to manage the uncertainty and its possible consequences, with the aim to support the dentist’s care for their patients. The understanding that uncertainty exists and the ability to acknowledge and be comfortable with it when making decisions should be addressed throughout our professional career, and thus ought to be developed during undergraduate education. Some suggestions on how teachers could target this are given in the paper. The article is available in full text here: https://onlinelibrary.wiley.com/doi/abs/10.1111/iej.13679
... Gail Geller suggests implementing a quantitative scale of the applicant's tolerance for ambiguity, as a greater tolerance for ambiguity is associated with a biopsychosocial worldview rather than a biomedical one. 438 However, changing the admissions process to accept students that are purportedly more capable of dealing with Barnard's existential discomforts is only one piece of the puzzle; William F. May argues that the admissions process is only the first step in the formation of medical professionals that are not equipped to provide ideal care: "The criteria for admission to medical school, the grading system that prevails there, the system for the placement of graduates in residencies, and eventual job references -all these hurdles and pressure points combine to emphasize the preeminent place of technical performance in the formation and career of the professional." 441 Indeed, this has been evidenced within the data presented in the themes identified in Chapter 4. Students are placed under pressures during all four years of medical school: adjusting to a new environment in which they are compared to other formerly high achieving undergraduates, preparing for a high-stakes standardized exam, adjusting again to a new, high-stakes environment in which grades are highly subjective and students are at the bottom of the medical hierarchy, and finally, applying for residency. ...
Thesis
Medical student burnout is currently incredibly common. Recent studies report that approximately 50 percent of students had scores indicative of burnout on the Maslach Burnout Inventory. Burnout can become chronic, and up to 73.2% of the afflicted fail to recover while they are trainees. This is significant because burnout profoundly affects the inner world of the physician and places them at a higher risk of depression, substance use disorder, and suicide; in turn, burnout impacts their professional behaviors and the quality of patient care. This dissertation explores the hypothesis that negative emotions that arise from unresolved ethical, technical, behavioral, and existential discomforts and their role in mediating burnout; this includes the discomforts experienced due to the lack of decision-making power held during medical training. I utilize an autonetnographic approach to understand how medical students on /r/medicalschool, an online news-aggregating forum, conceptualize and operationalize the term “burnout,” how they cope with burnout, and what barriers and attitudes they face that perpetuate a system that fosters burnout. This autonetnography is a study of spaces and interactions on a freely accessible, anonymous public forum. Within these spaces and interactions, I explore how the social, economic, and political forces present within medical education shape the ethical affordances that medical students have. Based on these understandings, I challenge the notion that medical student burnout is due to unresolved existential discomforts – an inability to come to terms with patients’ death and suffering – but is rather due to the creation of an Existential void. Students feel lost as they question the purpose of their training because of the incongruency between the values and moral norms professed and those practiced in medicine, and they experience being objectified when reduced to quantifiable metrics, such as board scores and clinical evaluations. With this new insight and understanding into medical student burnout, I propose changes that address the root cause of student burnout – ontological insecurity caused by real-world micro- and macro-economic pressures.
... We haven't found any difference between doctors and students in their TU-ITU; this confirms the idea that high TU is a selection (and self-selection) criterion for the medical profession (Geller, 2013). ...
Article
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Background. Tere is no generally accepted psychological understanding of how a doctor’s representation of risk and uncertainty afects professional medical decision-making. Te concept of a Unifed Intellectual and Personal Potential can serve as a framework to explain its multiple and multilevel regulation. Our objective was to research the connections between medics’ perceptions of risk and related personal factors. Design. Medical doctors were compared to diferent control groups to identify their personal and motivational characteristics in three studies. Study 1 assessed the motivational profle of doctors (using Edwards Personal Preference Schedule) in connection with their risk-readiness and rationality (measured by the Personal Factors of Decision-making questionnaire, also known as LFR) in a sample of 33 doctors, as compared to 35 paramedics and 33 detectives. Study 2 compared 125 medical students and 182 non-medical students to 65 doctors as to the levels of their risk perception (measured by Implicit Teories of Risk questionnaire, the LFR, and their direct self-esteem of riskiness¤ ), tolerance for uncertainty (measured by Budner’s questionnaire), and rating on the Big-Five personality traits (TIPI). Study 3 presented two new methods of risk perception assessment and investigated the connection between personality traits, risk reduction strategies, and cognitive representations of risk in 66 doctors, as compared to 44 realtors. Results. Study 1 found diferences between the doctors’, paramedics’, and investigators’ motivational profles. Te doctors’ motivations were not associated with conscious self-regulation. In Study 2, risk-readiness was positively related to tolerance for uncertainty (TU) and the self-esteem of riskiness. Te latter was signifcantly lower in doctors compared to the student groups and had diferent relationships with personality variables. In Study 3, doctors difered from realtors not only in their traits (i.e., being less willing to take risks), but also in their choices and greater integration of their risk representations. Conclusions. Te three studies demonstrated the multilevel processes behind the willingness to take risks and risk acceptance, as well as the relationship between the multilevel personality traits and doctors’ assessments of medical risks and their preferences in risky decision-making.
... Studies indicate that positive responses to uncertainty (e.g., excited emotions and information gathering behaviour) occur when it is appraised as beneficial (George & Lowe, 2019;Langer, 1994). As an individual's response to uncertainty can be modified through practice (Geller, 2013), this highlights the importance of learning how to manage one's affective responses to uncertainty (Brashers, 2001). ...
Article
Objective: The ability to tolerate uncertainty has been identified as a necessary capacity in healthcare workers. This study aims to explore experiences of uncertainty and coping among practicing psychologists. Method: Semi-structured interviews were conducted with 24 participants. A critical realist approach was employed and thematic analysis utilised. Results: Participants identified perceived causes of uncertainty which included, complex and risky clients, lack of therapeutic engagement and ethical dilemmas. Participants experienced primarily negative physiological, emotional and cognitive responses to uncertainty. Coping behaviours included seeking supervision, focusing on oneself, focusing on client-related activities, and avoiding clients associated with uncertainty. Experiences of uncertainty were noted to change over time. Conclusions: This paper supports the need to better understand how psychologists can be supported to manage uncertainty and its effects on professional practice. The role of training and supervision models in promoting strategies to support psychologists’ tolerance of uncertainty is highlighted.
... To address issues linked to poor tolerance of ambiguity and uncertainty among practicing physicians (e.g., excessive testing and referrals, physician wellbeing), 1-3 researchers suggest focusing on future physicians, including individual characteristics of medical school applicants. 4,5 From this perspective, sport background is a potential individual characteristic to consider in relation to future physicians' ambiguity and uncertainty tolerance because sport involvement is frequent among medical students. 8,9 The present study investigated this relationship specifically in third 9 year medical students who are just starting their clinical exposure. ...
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Purpose Involvement in sport is common among prospective medical students and may serve as a foundation for the psychological wellbeing of future physicians. This study examined the relationship between medical students’ sport background and their tolerance of ambiguity and uncertainty, an established factor in physician wellbeing and a key component in quality patient care. Method Sixty-one 3rd year medical students (50% females) at a large Canadian university responded to a web-based survey (62% response rate). The survey included the 29-item TAMSAD (Tolerance of Ambiguity in Medical Students and Doctors) scale and sport background measures (sport type and level of involvement). Analysis of variance and correlational analysis were performed. Results Analysis of variance indicated a significant mean difference in students’ TAMSAD scores based on sport type. Individual sport participants reported on average higher tolerance of ambiguity and uncertainty than team sport participants. However, in team sport participants, their tolerance of ambiguity and uncertainty tended to increase with an increase in sport involvement (from recreational to competitive). Discussion The gained insights are valuable as involvement in dedicated, extracurricular activities such as sport has not been studied in relation to ambiguity and uncertainty tolerance in medical students. The findings have implications for medical education and professional practice. Medical students and physicians could draw on the attributes and skills developed in sport when responding to ambiguity and uncertainty in clinical settings. Those without a sport background could learn and apply some of the strategies athletes use to tackle setbacks and uncertainty in high-stakes situations. Medical school admissions, curriculum designers, and educators could use the knowledge in developing interview questions, designing educational innovations, and selecting instructional strategies for teaching clinical reasoning and decision making. Future research should include qualitative studies to provide in-depth explanations for the relationships observed in this study.
... Conversely, those with low tolerance tend to deny, avoid, or minimize ambiguity and experience significant stress on account of it. In medical practice, low tolerance of ambiguity is associated with the biomedical model rather than a bio-psycho-social vision of care [23]. ...
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Medical Humanities approach is becoming an important action in the health curriculum. Art can play a central role in the training of care staff for the development of skills and for the humanization of the therapeutic path. The application of art as a tool for learning and its historical relationship with medicine can be a valid support for the development of skills such as observation, active listening, problem solving and empathy, useful for improving the profession and the relationship with the patient. It is possible to rediscover the link between art, medicine, and care to help health professionals to improve their activities and resilience. Particular methods such as that of the Visual Thinking Strategies (VTS) can help health students and professionals to become better actors in the care context.
... 12 Variance in tolerance for uncertainty by medical specialty may be appropriate, but some tolerance of uncertainty is probably a virtue regardless of medical specialty because low tolerance for uncertainty has been linked to increased test ordering, failure to follow evidence-based guidelines, and fear of medical malpractice. 13 Proposals have been made to use tolerance for uncertainty as a criterion during the medical student selection process or teach it in medical school. 14-17 But whether tolerance for uncertainty can be taught is a mostly unanswered question. ...
... Low tolerance for uncertainty has been associated with excessive test ordering, failure to comply with practice guidelines, increased patient charges, and other markers of poor clinical care. 5 Existing literature about communicating uncertainty is generally qualitative and focuses on patients' responses to physicians expressing uncertainty in primary care settings. The outcome of uncertainty communication depends upon the method of communication, patient type, and the source of uncertainty. ...
Article
Background and purpose Communicating uncertainty is an art requiring practice. The purpose of this study was to compare pedagogies for the instruction of pharmacy students in communicating definitive uncertainty. Educational activity and setting A case scenario featuring a busy physician asking a question without a definitive answer was directed to the pharmacy student using two pedagogies: (1) in-person standardized client and (2) virtual written case. Students provided self-assessments of their confidence in communicating uncertainty after completing the case utilizing a survey containing both rating scale questions and open-ended questions. Self-confidence within-group differences were compared using Wilcoxon signed-rank tests and between-group differences were compared using Mann-Whitney U tests. Responses to open-ended questions were descriptively analyzed for themes using qualitative assessment methods. Findings Both the in-person standardized client (70 to 81, P ≤ .001) and the virtual written case (74 to 85, P ≤ .001) significantly increased students' self-rated confidence to verbalize “I don't know” to a healthcare provider. No significant differences were observed between the pedagogies. However, students who participated in the virtual written case mentioned a desire for “additional practice opportunities” more frequently than students who participated in the in-person standardized client. Summary In-person standardized client and virtual written case are effective methods for increasing pharmacy student comfort with communicating definitive uncertainty. Further research is needed to instruct pharmacists in uncertainty communication.
Article
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. Relatedly, 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 minutes of data from purposively sampled HASS academics’ (n = 14) discussions to address the following research questions: (1) What teaching practices do HASS academics’ perceive as impacting learners’ uncertainty tolerance, and (2) How do HASS academics execute these teaching practices? The results extend current understanding of the moderating effects of education on uncertainty tolerance and supports prior findings that the anatomy learning environment is ripe for supporting learner uncertainty tolerance development. This study adds to growing literature on the powerful moderating effect education has on uncertainty tolerance and proposes translation of HASS uncertainty tolerance teaching practices to enhance anatomy education.
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A wide variety of ethical issues and needs arise in embodied educational practices for new health professionals. This chapter will first consider some core understandings about health professions learners and their embodied needs, namely, the inherently embodied nature of human life and healthcare practice and the overlapping, yet sometimes distinctive, needs of learners in the health professions. Specific virtues are proposed as important for healthcare professionals learning to provide excellent, embodied care for their patients. These virtues are epistemic humility, respect for the integrity of the patient as a person, tolerance for ambiguity, and a yearning for justice. Finally, this work will consider key ethical issues in embodied health professions education such as respect for the bodily needs and limits of learners, addressing damaging aspects of hidden curricula that socialise learners into patterns of disrespect, and questions about the safety of patients when they are practised on by novice health professionals.
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Physicians in residency training experience high levels of medical uncertainty, yet they are often hesitant to discuss uncertainty with parents. Guided by the theory of motivated information management and a multiple goals perspective, this mixed-methods longitudinal study examines associations among residents' tolerance of and reactions to uncertainty, efficacy communicating about uncertainty, and perceptions of parents' trust in them as physicians. To contextualize these associations, we also examined residents' task, identity, and relational goals when communicating about uncertainty with parents. We surveyed 47 pediatric residents at the beginning of each year of their residency program. As they progressed through their training, residents' uncertainty-related anxiety and reluctance to communicate uncertainty to parents decreased, and their efficacy communicating uncertainty with parents increased. Residents' concerns about bad outcomes remained unchanged. Residents pursued multiple, often conflicting, conversational goals when communicating uncertainty with parents. Results reveal important considerations for addressing how residents can manage their uncertainty in productive ways.
Article
Objectives Managing uncertainty is central to expert practice, yet how novice trainees navigate these moments is likely different than what has been described by experienced clinicians. Exploring trainees’ experiences with uncertainty could therefore help explicate the unique cues that they attend to, how they appraise their comfort in these moments, and how they enact responses within the affordances of their training environment. Methods Informed by constructivist grounded theory, we explored how novice emergency medicine trainees experienced and managed clinical uncertainty in practice. We used a critical incident technique to prompt participants to reflect on experiences with uncertainty immediately following a clinical shift, exploring the cues they attended to and the approaches they used to navigate these moments. Two investigators coded line‐by‐line using constant comparison, organizing the data into focused codes. The research team discussed the relationships between these codes and developed a set of themes that supported our efforts to theorize about the phenomenon. Results We enrolled 13 trainees in their first two years of postgraduate training across two institutions. They expressed uncertainty about the root causes of the patient problems they were facing and the potential management steps to take, but also expressed a pervasive sense of uncertainty about their own abilities and their appraisals of the situation. This, in turn, led to challenges with selecting, interpreting, and using the cues in their environment effectively. Participants invoked several approaches to combat this sense of uncertainty about themselves, rehearsing steps before a clinical encounter, checking their interpretations with others, and implicitly calibrating their appraisals to those of more experienced team members. Conclusions Trainees’ struggles with the legitimacy of their interpretations impact their experiences with uncertainty. Recognizing these ongoing struggles may enable supervisors and other team members to provide more effective scaffolding, validation, and calibration of clinical judgments and patient management.
Article
Background: To our knowledge there has never been a longitudinal, multi-institutional empirical study of the attitudinal and interpersonal orientations correlated with GHHS membership status. Approach: We used the American Medical Association Learning Environment Study (LES) data set to explore attitudinal correlates associated with students whose behaviors are recognized by their peers as being exceptionally humanistic. Specifically, we examined whether empathy, patient-centeredness, tolerance of ambiguity, coping style, and perceptions of the learning environment are associated with GHHS membership status. We further considered to what extent GHHS members arrive in medical school with these attitudinal correlates and to what extent they change and evolve differentially among GHHS members compared to their non-GHHS peers. Between 2011 and 2015, 585 students from 13 North American medical schools with GHHS chapters participated in the LES, a longitudinal cohort study using a battery of validated psychometric measures including the Jefferson Scale of Empathy, Patient-Practitioner Orientation Scale and Tolerance of Ambiguity Questionnaire. In the final survey administration, students self-identified as GHHS inductees or not (non-GHHS). T tests, effect sizes, and longitudinal generalized mixed-effects models examined the differences between GHHS and non-GHHS students. Results: Students inducted into GHHS scored significantly higher on average over 4 years than non-GHHS inductees on clinical empathy, patient-centered beliefs, and tolerance of ambiguity. GHHS students reported higher levels of empathy and patient-centeredness at medical school matriculation. This difference persists in the 4th year of medical school and when controlling for time, race, gender, and school. Conclusions: GHHS inductees enter medical school with different attitudes and beliefs than their non-GHHS classmates. Although humanistic attitudes and beliefs vary over time during students' 4 years, the gap between the two groups remains constant. Medical schools may want to consider selecting for specific humanistic traits during admissions as well as fostering the development of humanism through curricular interventions.
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Purpose: Tolerance for ambiguity (TFA) is important for physicians, with implications for ethical behavior and patient care. This study explores how medical students' TFA changes from matriculation to graduation and how change in empathy and openness to diversity are associated with this change. Method: Data for students who took the Matriculating Student Questionnaire (MSQ) in 2013 or 2014 and the Medical School Graduation Questionnaire (GQ) in 2017 or 2018 were drawn from the Association of American Medical Colleges (n = 17,221). Both the MSQ and GQ included a validated TFA scale and a shortened version of the Interpersonal Reactivity Index; the MSQ also included an openness to diversity scale. Tercile groups were used to assess how TFA changed from the MSQ to GQ, and regression analyses were used to assess associations between change in TFA and openness to diversity and between change in TFA and change in empathy. Results: Mean TFA scores decreased (d = -.67) among students with the highest TFA at matriculation but increased (d = .60) among students with the lowest TFA at matriculation. Regression results showed that change in TFA was significantly and positively associated with change in empathy (beta = .05, P < .001) and that openness to diversity (as reported at matriculation) were significantly and positively associated with TFA at graduation (beta = .05, P < .001). Conclusions: This is the first nationally representative study to suggest that medical students' TFA changes over time, but in different directions depending on TFA at matriculation. TFA over time was also associated with change in empathy and openness to diversity. Medical schools should consider strategies to assess TFA in their admissions processes and for cultivating TFA throughout the learning process.
Article
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.
Article
Experiences of wonder should be valued, protected, and promoted in academic settings. Identification of learning environments and interventions that cultivate students’ capacity for wonder (CfW) first requires a means to measure it. We used a mixed-methods approach to develop and validate a measure of CfW. In the qualitative component (Studies 1–3), we content analyzed open-ended descriptions of wonder (Study 1), interviewed people whom others identified as exemplifying CfW (Study 2), and conducted focus groups to review, for quality and consistency, and to establish face validity of, potential inventory items that capture wonder (Study 3). These items were then subjected to standard psychometric analyses in the quantitative component of our methods (Studies 4–6). In Study 4, exploratory factor analysis (EFA) revealed CfW may contain two subscales representing “Perspective Shifting” and “Emotional Reawakening.” In Study 5, confirmatory factor analysis (CFA) corroborated this two-factor structure in an independent sample and longitudinally across 17 months, establishing a final 10-item CfW scale; In Study 6, we assessed the scale’s discriminant and convergent validity. CfW was weakly to moderately correlated with theoretically related constructs of curiosity, tolerance for ambiguity, humility, and empathy. We conclude with a discussion of future directions and potential applications.
Article
Issue: Although there is consensus on the importance of including ethics in the medical school curriculum, there is wide variation in how this topic is taught. Recent literature also questions the effectiveness of current ethical teaching methods in changing student attitudes and future behavior. Furthermore, from the student perspective, there is a marked disconnect between the stated importance of and lack of effort in ethics courses. Evidence: Applying a student perspective of the hidden curriculum, as well as reviewing and applying insight from the available literature, we advocate for alignment of instructional design, content, and assessments. This article provides specific recommendations to increase student engagement in ethics courses and concludes by discussing whether a lack of engagement is attributable to intrinsic qualities of medical students in addition to pedagogical technique and educational setting and culture. Implications: This article has practical suggestions for medical educators to improve their ethics courses, leading to more well-rounded and thoughtful physicians.
Article
Intolerance of ambiguity among medical students is associated with negative attitudes towards psychosocially complex patients. In this paper, the authors evaluated the feasibility of a 3.5-hour workshop aimed at fostering tolerance for ambiguity in medical students through semi-structured interactions with horses that functioned as experiential surrogates for ambiguity. Among 26 first-year medical students who participated in the feasibility assessment, an overwhelming majority rated the workshop as academically valuable and recommended that it be offered again in the future. After feasibility was established, an additional group of 7 first-year medical students and 5 fourth-year students completed Budner’s Tolerance of Ambiguity scale before and after the workshop to provide preliminary data on its effectiveness. The post-workshop mean scores on the Budner scale were lower than pre-workshop mean scores, suggesting that students developed greater tolerance for ambiguity following the workshop. This difference was statistically significant among the first-year students, but not among the fourth-year students. Our findings demonstrate that the equine-facilitated workshop is feasible and can potentially help medical students develop greater tolerance for ambiguity.
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Background: Certain personal attributes, such as perfectionism and tolerance of ambiguity, have been identified as influential in high achieving students. Medical students have been identified as high achievers and perfectionistic, and as such may be challenged by ambiguity. Medical students undertake a long and challenging degree. Personality has been shown to influence the well-being and coping and may equip some students to better cope with challenges. This paper examines the association between temperament and character personality profiles with measures of tolerance of ambiguity and with both adaptive and maladaptive constructs of perfectionism. Methods: A self-report questionnaire collected data on a sample of 808 Australian medical students in 2014 and 2015. Personality was measured using the Temperament and Character Inventory (TCIR-140) and classified traits as profiles using a latent class analysis. Two profiles were found. Profile 1 was characterized by low-average levels of Harm Avoidance, and high to very high levels of Persistence, Self-Directedness and Cooperativeness. Moderately-high levels of Harm Avoidance and high levels of Persistence, Self-Directedness and Cooperativeness characterized Profile 2. Moderation regression analyses were conducted to examine the association between the personality profiles with levels of Tolerance of Ambiguity (MSAT-II), Perfectionism-Concern over Mistakes and Perfectionism-High Standards (FMPS), considering demographic characteristics. Results: Students with Profile 1 were higher in levels of Tolerance of Ambiguity, and Perfectionism-High Standards, and lower levels of Perfectionism-Concern over Mistakes compared to Profile 2. These findings remained statistically significant after adjusting for age and gender. A significant personality by age interaction on Tolerance of Ambiguity was found. While higher levels of Tolerance of Ambiguity were associated with older age overall, it remained low across age for students with a personality Profile 2. Conclusions: A particular combination of personality traits was identified to be associated with low Tolerance of Ambiguity and high levels of maladaptive Perfectionism. An intolerance of ambiguity and over concern about mistakes may be maladaptive and underlie vulnerability to stress and poor coping. The psychobiological model of personality provides insight into traits that are stable and those that can be self-regulated through education and training. The interaction between biological mechanisms and socio-cultural learning is relevant to a sample of medical students because it accounts for interaction of the biological or innate aspects of their personal development within an intense and competitive learning environment of medical school.
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Tolerance of uncertainty is an important skill among general practitioners (GPs). Our aim was to study fifth-year medical students' feelings related to facing uncertainty and fears of making mistakes in medical decisions. Further, we studied the associations of intolerance of uncertainty with demographic factors, the students' fears of making mistakes, and their views of a GP's work prior to their ultimate course in general practice. A questionnaire-based survey was carried out among the fifth-year medical students prior to their main course in general practice at the University of Helsinki. The questionnaire included demographic variables and inquired about their views of their own tolerance of uncertainty, fear of making mistakes, and of a GP's work overall. During the years 2008--2010, 307/359 medical students (mean age 25.7 years, 64% females) responded. Of the respondents, 22% felt they had difficulty tolerating uncertainty when making medical decisions. Females reported that they tolerated uncertainty poorly more often (27%) than did males (11%). Those tolerating uncertainty more poorly were more often afraid of making mistakes (100% versus 86%). This group more often considered a GP's work too difficult and challenging than did others. Poor self-reported tolerance of uncertainty among medical students is associated with considering a GP's work too challenging.
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In the model of Generalised Anxiety Disorder (GAD) proposed by Dugas, Gagnon, Ladouceur, and Freeston (1998), Intolerance of Uncertainty (IU) plays a central role in the acquisition and maintenance of worries. A similar concept, Intolerance of Ambiguity (IA) was introduced by Frenkel-Brunswik 50 years ago. For decades, IU has been confused with IA. Researchers have applied them interchangeably. The main goal of this paper is to clarify and differentiate the notions of IU and IA, as well as to suggest new research avenues.
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Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.
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PURPOSE: To explore the association between the attitudes of primary care physicians toward uncertainty and risk taking, as measured by a validated survey, with resource use in a Medicare HMO. DESIGN: All primary-care internists (n=20) in a large, multi-specialty clinic were surveyed to measure their attitudes about uncertainty and risk taking using three previously developed scales. Results were linked with administrative data for 792 consecutive patients in a recently created Medicare HMO. The patients' index visits occurred between April 1, 1995, and November 30, 1995. ANALYSIS: Charges stemming from several claim types (primary care and subspecialty physician, laboratory, radiology, and ambulatory procedures) in the 30 days following the index visit were summed. The physician scales were dichotomized at the median to seek unadjusted associations with charges. Generalized estimation equations were used to account for the correlation of charges resulting from patients' being nested within physicians and adjusted for physician characteristics (age, sex, years in practice) and patient characteristics (age, sex, comorbidity). MAIN RESULTS: The physician response rate was 90%. Most physicians (90%) were male. The mean age of the patients was 74 years, and 69% were female. The mean cost (+/-SD) per patient was $621.61+/-1,737.31. From the unadjusted analysis, high "anxiety due to uncertainty" was associated with higher patient charges ($197.85 vs $158.21, p=0.01). From the multivariable analysis, each standard deviation increase in "anxiety due to uncertainty" (3.5 points) corresponded to a 17% increase in mean charges (p < 0.01) and each similar increase in "reluctance to disclose uncertainty to patients" (1.92 points) corresponded to a 12% increase (p=0.03). However, increasing "reluctance to disclose mistakes to physicians" and increasing physician risk-taking propensity were associated with decreased total charges [-10% per standard deviation (1.34 points), p=0.02, and -8% per standard deviation (3.26 points), p=0.02, respectively]. CONCLUSION: Physician attitudes toward uncertainty were significantly associated with patient charges. Further investigation may improve prediction of patient-care charges, offer insight into the medical decision-making process, and perhaps clarify the relationship between cost, uncertainty, and quality of care.
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Despite widespread interest in ambiguity tolerance and other information-related individual differences, existing measures of ambiguity tolerance are conceptually disparate and are often psychometrically weak. This paper presents evidence of reliability and validity for a 13-item measure of ambiguity tolerance (MSTAT-II) based on a definition of ambiguity tolerance as an orientation, ranging from aversion to attraction, toward stimuli that are complex, unfamiliar, and insoluble. The MSTAT-II addresses each basic type of ambiguous stimulus, contains fewer items than many other scales, and reduces references to specific contexts and objects not directly related to ambiguity. Data from three studies using diverse samples and measures, including other popular ambiguity tolerance scales, were examined, and the results suggest the MSTAT-II may improve upon other paper-and-pencil measures of ambiguity tolerance.
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Aversion to "ambiguity"-uncertainty about the reliability, credibility, or adequacy of risk-related information-is an important problem that may influence judgments and decisions about medical interventions. Ambiguity aversion (AA) varies among individuals, however, and has been understudied in the health domain. To explore this phenomenon further, we developed a new theory-based measure of aversion to ambiguity regarding medical tests and treatments, and examined the prevalence and association of AA with sociodemographic factors. The "AA-Med" scale was developed using a large survey sample of the U.S. public (n = 4,398), and scale psychometric properties and the population distribution of AA were evaluated. The scale demonstrated acceptable reliability (alpha = .73) and validity as ascertained by association with respondents' interest in a hypothetical ambiguous cancer screening test. Ambiguity aversion (AA) was associated with older age, non-White race, lower education and income, and female sex. The AA-Med scale is a promising new measure, and AA is associated with several sociodemographic factors. We discuss implications of these findings and potential applications of the scale for future research.
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Primary care is an endeavor marked by breadth, complexity, and more clinical uncertainty than all non-primary care specialties except psychiatry. This is significant, as uncertainty is associated with a variety of troublesome economic and clinical indicators. Researchers have identified the three types of cognitive resources needed to combat uncertainty (technical, personal, or conceptual), as well as the affective stress reactions physicians have when confronted with uncertainty. In this study, we explored the relationship between primary care physicians' stress reactions to uncertainty and the conceptual resource of epistemology. Using Likert-type measures of epistemology and stress reactions to uncertainty, we conducted a cross-sectional survey with 78 board-certified and resident physicians in primary care. A simple bivariate regression analysis was performed to identify the relationship between epistemology and stress reactions to uncertainty (Model 1), and a multivariate regression analysis was performed to test for the independent effect of epistemology on stress reactions to uncertainty while controlling for gender, specialty, and professional development status (Model 2). Physician epistemology and stress reactions to uncertainty were significantly related in both models. Among primary care physicians, a biopsychosocial epistemology is associated with less stress reactions to uncertainty, and a biomedical epistemology is associated with more stress reactions to uncertainty.
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Reactions to uncertainty in clinical medicine can affect decision making. To assess the extent to which radiologists' reactions to uncertainty influence diagnostic mammography interpretation. Cross-sectional responses to a mailed survey assessed reactions to uncertainty using a well-validated instrument. Responses were linked to radiologists' diagnostic mammography interpretive performance obtained from three regional mammography registries. One hundred thirty-two radiologists from New Hampshire, Colorado, and Washington. Mean scores and either standard errors or confidence intervals were used to assess physicians' reactions to uncertainty. Multivariable logistic regression models were fit via generalized estimating equations to assess the impact of uncertainty on diagnostic mammography interpretive performance while adjusting for potential confounders. When examining radiologists' interpretation of additional diagnostic mammograms (those after screening mammograms that detected abnormalities), a 5-point increase in the reactions to uncertainty score was associated with a 17% higher odds of having a positive mammogram given cancer was diagnosed during follow-up (sensitivity), a 6% lower odds of a negative mammogram given no cancer (specificity), a 4% lower odds (not significant) of a cancer diagnosis given a positive mammogram (positive predictive value [PPV]), and a 5% higher odds of having a positive mammogram (abnormal interpretation). Mammograms interpreted by radiologists who have more discomfort with uncertainty have higher likelihood of being recalled.
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There is considerable ambiguity in the subjective dimensions that comprise much of the relational dynamic of the clinical encounter. Comfort with this ambiguity, and recognition of the potential uncertainty of particular domains of medicine (e.g.--cultural factors of illness expression, value bias in diagnoses, etc) is an important facet of medical education. This paper begins by defining ambiguity and uncertainty as relevant to clinical practice. Studies have shown differing patterns of students' tolerance for ambiguity and uncertainty that appear to reflect extant attitudinal predispositions toward technology, objectivity, culture, value- and theory-ladeness, and the need for self-examination. This paper reports on those findings specifically related to the theme of uncertainty as relevant to teaching about cultural diversity. Its focus is to identify how and where the theme of certainty arose in the teaching and learning of cultural diversity, what were the attitudes toward this theme and topic, and how these attitudes and responses reflect and inform this area of medical pedagogy. A semi-structured interview was undertaken with 61 stakeholders (including policymakers, diversity teachers, students and users). The data were analysed and themes identified. There were diverse views about what the term cultural diversity means and what should constitute the cultural diversity curriculum. There was a need to provide certainty in teaching cultural diversity with diversity teachers feeling under considerable pressure to provide information. Students discomfort with uncertainty was felt to drive cultural diversity teaching towards factual emphasis rather than reflection or taking a patient centred approach. Students and faculty may feel that cultural diversity teaching is more about how to avoid professional, medico-legal pitfalls, rather than improving the patient experience or the patient-physician relationship. There may be pressure to imbue cultural diversity issues with levels of objectivity and certainty representative of other aspects of the medical curriculum (e.g.--biochemistry). This may reflect a particular selection bias for students with a technocentric orientation. Inadvertently, medical education may enhance this bias through training effects, and accommodate disregard for subjectivity, over-reliance upon technology and thereby foster incorrect assumptions of objective certainty. We opine that it is important to teach students that technology cannot guarantee certainty, and that dealing with subjectivity, diversity, ambiguity and uncertainty is inseparable from the personal dimension of medicine as moral enterprise. Uncertainty is inherent in cultural diversity so this part of the curriculum provides an opportunity to address the issue as it relates to patient care.
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I. Are there uncertainties that are not risks? 643. — II. Uncertainties that are not risks, 647. — III. Why are some uncertainties not risks? — 656.
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There is need for a teaching programme aiming to impart a tolerance of error to undergraduate medical students. The implementation of such a programme may have to challenge the institutional norms that encourage authoritarianism, intolerance of uncertainty and denial of error. Acceptance of error is a prerequisite for its candid reporting, and reporting of errors is a prerequisite for their analysis with a view to their prevention. A curriculum on medical error may, therefore, not only help medical students cope with their future mistakes, but also reduce their frequency. Teaching intervention aiming to promote an acceptance of medical error as both inevitable and reducible may also encourage students' epistemological development by making them realize that their doubts and uncertainties are shared by their peers and instructors.
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Background: Health care is increasingly characterized by uncertainty and turbulence. In an environment of rapid change, flexibility is critical to the success of managers and organizations. Future physician executives must also be open to change and must be able to deal with the uncertainties of management; they must be able to tolerate the ambiguity in management situations. Method: This study uses tolerance of ambiguity measures to analyze students at six medical schools offering dual-degree (MD/MBA) programs. Students enrolled in dual-degree programs were assessed and compared with a control group of traditional medical students. Results: MD/MBA students exhibit a higher tolerance of ambiguity than traditional medical students. Findings: As a characteristic associated with leadership ability, tolerance of ambiguity offers a potential indicator of future success as a physician executive. As such, tolerance of ambiguity might be used for selective admissions to medical school and as an indicator of a student's potential to transition between clinical and management functions. As students match personality traits with career choices, those who serve their learning needs must anticipate differences across selected disciplines, roles, and responsibilities.
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This paper reviews the scattered and diffuse literature on the tolerance of ambiguity construct (AT). The work by Frenkel-Brunswik (1948) is considered in some detail to help explain the origin of the concept as well as its diffusion to many areas of psychology. Second, thirty years of correlational research, which looks at the studies correlating AT measures with a variety of psychological variables, are reviewed. Third, evidence for the differential distribution of AT among particular groups is reviewed. Fourth, the psychometric properties of the various self-report AT measures are considered in some detail. The two final sections look at organizational and cultural correlates of AT (the areas currently most interested in the AT concept). The conclusion attempts to explain varying patterns of interest in the AT construct and its current status.
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Despite significant advances in scientific knowledge and technology, ambiguity and uncertainty are still intrinsic aspects of contemporary medicine. To practice confidently and competently, a physician must learn rational approaches to complex and ambiguous clinical scenarios and must possess a certain degree of tolerance of ambiguity. In this commentary, the authors discuss the role that ambiguity and uncertainty play in medicine and emphasize why openly addressing these topics in the formal medical education curriculum is critical. They discuss key points from original research by Wayne and colleagues and their implications for medical education. Finally, the authors offer recommendations for increasing medical student tolerance of ambiguity and uncertainty, including dedicating time to attend candidly to ambiguity and uncertainty as a formal part of every medical school curriculum.
Article
Little published research details the risk factors for the decline in students' attitudes toward underserved populations during medical school. The authors assessed the association between this attitude change and intolerance of ambiguity (the tendency to perceive novel or complex situations as sources of threat), since treating underserved populations often involves a high level of complexity. The University of New Mexico School of Medicine administered a survey assessing attitudes toward underserved populations at matriculation and at graduation to seven consecutive medical school classes (matriculation years 1999 to 2005). The university also administered a survey measuring tolerance of ambiguity at matriculation. Five hundred twenty-nine students were eligible to complete both surveys between 1999 and 2009. Three hundred thirteen (59%) students completed the attitude survey at matriculation and graduation. Attitude scores for a majority of students (69%) decreased from matriculation to graduation. Changes in scores ranged from +25 to -35; the average change was -4.5. Linear regression analysis showed that those who were tolerant of ambiguity (top 20% of tolerance of ambiguity scores) were significantly less likely to have declines in attitudes toward the underserved; the coefficient was 3.69 (P = .003). Other factors independently associated with maintaining high attitude scores were being female and starting medical school at age 24 or younger. Attention to, and practice with, ambiguous situations may help moderate decreases in attitudes toward underserved populations. Medical education should address the fact that physicians face much ambiguity and should offer students tools to help them respond to ambiguous clinical situations.
Article
Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.
Article
Clinical trials of novel agents often present several layers of ethical challenge. Because time and resources for ethical and safety review are limited, how investigators, IRBs, and regulators allocate attention to a trial's various safety dimensions itself represents a critical ethical question. In what follows, I use the example of a Parkinson's disease gene transfer trial to show how risks involving unknown probabilities or outcomes (ambiguity), might sometimes draw attention away from risks that involve known probabilities or outcomes. This potentially undermines the goal of 'systematic and nonarbitrary analysis of risk' during ethical review. To counteract the possible effects of such attention biases, I propose that reviewers develop 'cognitive aids' like lists and, where appropriate, set aside time to discuss non-ambiguous risks. I also propose further research for addressing and understanding how attention allocation, emotion, and ambiguity influence ethical decision-making.
Article
This study was designed to determine the degree to which clinical genetics professionals are comfortable with grief and loss, whether discomfort with grief and loss is associated with clinician distress, and what factors predict comfort with grief and loss for the purpose of developing recommendations for support and training. We surveyed 300 clinical geneticists (MDs), genetic counselors (GCs) and genetic nurses randomly selected from their professional associations. Out of 225 eligible clinicians, 172 completed surveys (76% response rate). The vast majority of respondents have clinical interactions with patients and families who are experiencing grief, loss and/or death. However, nearly 20% of respondents reported that they did not feel 'comfortable in the presence of grief and loss'. Twenty-nine percent of respondents disagree or strongly disagree that they 'have been adequately trained to address issues of death, dying, grief/bereavement, and end of life care'. Reported discomfort with grief and loss was strongly correlated with clinician distress. Predictors of comfort with grief and loss included perceived adequacy of training, tolerance for uncertainty, significant personal experiences of loss and deriving meaning from patient care. In conclusion, as follows. A significant minority of clinical genetics professionals experience discomfort in the presence of grief and loss, and feel inadequately prepared for such experiences. Greater attention should be paid to training clinicians in how to deal with grief and loss, and supporting them through such difficult experiences in an effort to reduce their distress.
Article
Intolerance of ambiguity is the perception of ambiguous situations as threatening. It has often been measured using Budner's 1962 intolerance of ambiguity scale in studies of medical students and physicians. To examine the test-retest reliability of the scale among that population, we administered it to all 171 entering medical students at one medical school immediately prior to beginning classes and readministered it to them six to nine weeks later with an 81% follow-up rate. The Pearson correlation between the first and second administrations was .64, showing moderate reliability during this stressful period in medical socialization. The internal reliability of the scale remained constant; the alpha was .64 at the first administration and .63 at follow-up. These data indicate moderate reliability of Budner's intolerance of ambiguity scale when respondents are medical students.
Article
The art of clinical medicine involves learning to deal with varying levels of ambiguity and uncertainty. Tolerance of ambiguity was examined by giving Budner's Intolerance of Ambiguity Scale to a sample of 37 family practice residents from a university hospital residency and 22 from a community hospital residency. Residents in both the community and university programs had similar scores. No differences existed between men and women. Compared to studies of medical students, first-year family practice residents were slightly more intolerant of ambiguity. However, intolerance of ambiguity was lower among third-year residents, suggesting that as training advances, residents may become more tolerant of ambiguity. The residency training process may lead to a reduction in intolerance of ambiguity, which produces physicians who can deal with the ambiguity and uncertainty of clinical practice.
Article
At one medical school in 1982, 175 entering medical students indicated their medical specialty preferences, completed Budner's Intolerance of Ambiguity scale, and supplied demographic information. Most (91%) completed medical school, and their specialty choices at graduation from the National Resident Matching Program were recorded. Initial specialty preference was a poor predictor of later specialty choice (R2 = .11). The students' intolerance of ambiguity was not significantly associated with either their initial medical specialty preferences or their specialty choices at graduations. This finding supports previous studies showing that specialty preferences changed dramatically during medical school, but does not reveal any support for a relationship between students' initial intolerance of ambiguity and their specialty selections.
Article
The practice of medicine has always been characterized by uncertainty. Yet, attempts to study tolerance for uncertainty in medicine have been few, and limited to its influence on specialty preferences and test-ordering behavior. In particular, studies have not investigated how the process of socialization into the medical profession affects tolerance for uncertainty. Based on the assumption that uncertainty and ambiguity are related concepts, a modified version of a tolerance for ambiguity scale was used to study Johns Hopkins medical students' (N = 386) tolerance for ambiguity (TFA) through 4 yr of medical school. In addition, using alcoholism as an example of a clinically ambiguous condition, the association between students' tolerance for ambiguity and their perceived role in diagnosing and treating alcoholism was also investigated. Results indicate that tolerance for ambiguity (1) does not change throughout medical school, (2) is lower among men, whites and students who are younger when they begin medical school, (3) is higher among prospective psychiatrists than surgeons, and (4) is lower among students who do not feel responsible for diagnosing and treating alcoholism. These findings suggest that tolerance for ambiguity may, indeed, affect practitioners' career choices and performance and that selection of medical students may be more important than medical training per se in influencing students' tolerance for ambiguity. If medical schools admitted students who possess a high tolerance for ambiguity, quality of care for ambiguous conditions might improve, imbalances in physician supply and practice patterns might be reduced, and the increasing ambiguity in medical practice might be better acknowledge and accepted.
Article
Although variations in physicians' practice patterns and use of resources are well documented, the reasons for these variations are less well understood. The uncertainty inherent in patient care may be one explanation. Existing measures of intolerance to uncertainty, developed in contexts outside of patient care, fail to explain these variations. To address this limitation, the Physicians' Reactions to Uncertainty scale was developed. A questionnaire containing an initial pool of 61 items was mailed to a random sample of 700 physicians in North Carolina and Oregon, stratified by specialty. The items covered nine areas of physicians' reactions to uncertainty derived from interviews with physicians and a definition of the concept affective reactions to uncertainity in patient care. Factor analysis of the 428 responses received yielded two primary factors that accounted for 58% of the common variance among the 61 items. Items with unambiguous loadings on these factors defined two reliable and readily interpretable subscales: Stress from Uncertainty (Cronbach's alpha = 0.90, 13 items) and Reluctance to Disclose Uncertainty to Others (alpha = 0.75, 9 items). By virtue of its clarity and good psychometric properties, this new measure promises insights into the role that uncertainty plays in physicians' resource utilization and practice patterns.
Article
Intolerance of ambiguity is the perception of ambiguous situations as a threat. Medical students with differing levels of intolerance of ambiguity may select medical specialties based upon the amount of ambiguity existing in the practice of each specialty. A cross-sectional survey at one state university administered Budner's Intolerance of Ambiguity Scale to all entering first-year medical students for four consecutive years (N = 609) to investigate patterns of intolerance of ambiguity in relationship with demographic variables and initial medical specialty preference. The medical students in this study were more intolerant of ambiguity than those first studied by Budner in 1962. Students entering in 1985 were slightly more intolerant of ambiguity than students in 1988. Students age 23 and older were less intolerant of ambiguity than students 18-22 years old. Men and students with natural/physical science undergraduate majors were more intolerant of ambiguity than their counterparts. However, medical specialty preference was not related to intolerance of ambiguity. Intolerance of ambiguity may be a personality trait or a learned characteristic, and needs further investigation.
Article
This paper offers a critique of the idea of 'uncertainty' in the sociology of medicine, particularly in the context of studies of medical education. The work of Renée Fox is used as the main example of the work against which this criticism is levelled. It is argued that the idea of 'training for uncertainty' has been over-emphasized in previous literature. The notion of 'training for certainty' is proposed as a corrective. Finally, however, it is argued that an adequate phenomenology of medical knowledge, education and practice must recognize 'certainty' and 'uncertainty' as two different 'attitudes', which may co-exist simultaneously, reflecting different practical and theoretical interests.
Article
Modern developments of scientific medicine have uncovered and created uncertainties and risks that were previously not known or experienced; the stakes have become very much higher. The rise in public expectation, however, is paralleled by a lowered tolerance of uncertainty. Metaphors of "deliverance" and "disaster" abound in discussions of scientific discovery, reflecting differing conceptions and philosophies about errors and mistakes, and the role they play in the physical universe, the biosphere, and human affairs. These concerns highlight the difficulties and dilemmas of finding scientifically adequate, culturally appropriate, and socially effective ways of appraising and controlling risk.
Article
Despite uncertainties in medicine, attempts to study physicians' tolerance for uncertainty have been few, and limited by the measurement instruments available. This paper describes development of a modified tolerance for ambiguity (TFA) scale, and correlates it with several physician characteristics and reported behaviors. Eighteen TFA items were included in a national survey of physicians' knowledge and attitudes about genetic testing. Sixty-five percent (n = 1,140) of 1,759 obstetricians, pediatricians, internists, family practitioners, and psychiatrists responded. After psychometric analyses, the scale was reduced to 7 items, demonstrating an acceptable reliability (Cronbach's alpha = .75). TFA was higher among psychiatrists than other specialties, among those who were older when they graduated from medical school, and among those willing to offer a new low-cost, accurate predictive test when none of their colleagues do. TFA was lower among those who indicated that attendance at religious services was important, among those who would make a recommendation to their patients regarding pregnancy termination after prenatal diagnosis, and among those who would withhold negative genetic test results. Future research is needed on the scale itself, and to assess factors affecting TFA, such as its susceptibility to modification, and its potential association with clinical practice in other areas of medicine that are characterized by ambiguity.
Article
There is need for a teaching programme aiming to impart a tolerance of error to undergraduate medical students. The implementation of such a programme may have to challenge the institutional norms that encourage authoritarianism, intolerance of uncertainty and denial of error. Acceptance of error is a prerequisite for its candid reporting, and reporting of errors is a prerequisite for their analysis with a view to their prevention. A curriculum on medical error may, therefore, not only help medical students cope with their future mistakes, but also reduce their frequency. Teaching intervention aiming to promote an acceptance of medical error as both inevitable and reducible may also encourage students' epistemological development by making them realize that their doubts and uncertainties are shared by their peers and instructors.
Article
Management of the dying patient often elicits anxiety in physicians. This study identified the association of physicians' personal fear of death, tolerance of uncertainty, and attachment style with physician attitudes toward dying patients. Four psychological scales were distributed to family practice residents located in Texas, Missouri, and Maine. The scales were "Death Anxiety," "Death Attitudes," "Physicians' Reactions to Uncertainty," and "Experiences in Close Relationships." The scores from the measures and demographic data were used to determine which factors were associated with physician attitudes toward caring for terminally ill patients. Completed surveys were received from 157 residents. Younger residents (< 30 years) reported more stress from uncertainty and were more uncomfortable with the care of dying patients. Residents who reported higher death anxiety were also more uncomfortable with caring for dying patients. In a multivariate analysis, uncertainty, death anxiety, and age predicted 26% of the total outcome variance of the death attitudes score. Physician tolerance of uncertainty plays a significant role in physician attitudes toward the dying patient. Our findings suggest that decreasing physicians' stress from uncertainty by educating them in the management of the dying patient may improve their attitude toward death and may better prepare them to provide end-of-life care.
Article
The authors' threefold purpose in this article was to (a) propose a model of the relationship between the emotional aspects of physicians' attitudes to medical errors (e.g., fear of litigation) and their functional consequences (e.g., tendency to defensive practice); (b) develop a measure of some of these attitudes; and (c) provide empirical support for some of the relationships in the model. Medical students and physicians responded to a questionnaire concerning their attitudes toward uncertainty and medical error. The dependent variables were two dimensions of attitudes to uncertainty ("reluctance to disclose uncertainty" and "stress from uncertainty") and four dimensions of attitudes to medical error ("fear of litigation," "support for self-regulation," "tendency to defensive practice," and "self-disclosure of errors"). Stress from uncertainty correlated with fear of malpractice litigation and defensive practice. They concluded that interventions that aim to increase physicians' tolerance of uncertainty may also reduce their fear of malpractice litigation and their tendency to defensive practice.
Article
Evidence-based medicine helps physicians appraise the latest and best evidence and incorporate patient's values in reaching a shared clinical decision. However, many decisions in medicine are made in the paucity of best evidence. Medical uncertainty remains inherent in clinical practice and contributes to significant variability in the way physicians and patients manage medical problems. Physicians and patients have varying degrees of tolerance for uncertainty. Intolerance to uncertainty among physicians results in increased test ordering tendencies, variability in medical treatment, failure to comply with evidence-based guidelines, and even guide career choices. Factors that result in the variability of physicians' interpretation of an effective treatment include: patient factors (prioritizing some factors over others), physician factors (lack of knowledge, lack of resources, medical uncertainty), and environmental factors (limitation of time and practice). Several approaches that have been found useful in implementing evidence in clinical practice include: sending reminders to prompt physicians to perform patient-related clinical activities, introducing computer information systems to support practice, and using interactive education interventions to teach newer skills and challenge negative attitudes. Passive educational approaches, like dissemination of guidelines and didactic lectures, are usually less useful in changing behavior. Among the techniques found to be useful for managing uncertainty are shared decision making, meticulous history taking, and physical examination, excluding worrisome differential diagnosis and establishing trust in patients. The role of future studies in assessing the outcome of multiple evidence-based strategies in situations of medical uncertainty remains to be explored.
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