Examining Uncertainty in Internal Medicine Education: a Mixed-Methods Study

Abstract

Objective: Tolerance of uncertainty is recognized by the ACGME as an important competency for physicians. Predictions for the future role of physicians in settings where informatics and algorithms aid decisions points to the importance of embracing uncertainty in order to 1) avoid pitfalls of uncertainty and 2) develop trusting and meaningful doctor-patient relationships. This study aimed to identify perceptions and behaviors related to uncertainty. Study Design and Setting: This mixed-methods study explored perceptions and manifestations of uncertainty in the hospital setting at a US academic medical center. Qualitative methods included observations of clinical activities and interviews with resident and attending physicians. A cross-sectional survey utilized three validated survey instruments assessing perceptions of uncertainty, the learning environment, and symptoms of burnout. Results: Four ethnographic themes were identified: 1) acknowledging uncertainty 2) sharing uncertainty in the healthcare environment 3) strategies for dealing with uncertainty: actions and inactions, and 4) understanding the impact of uncertainty on the patient. Six qualitative themes were identified in interviews: 1) awareness of uncertainty, 2) uncertainty is multi-dimensional, 3) challenges with uncertainty, 4) ways of dealing with uncertainty, 5) the impact of uncertainty in the learning environment, and 6) desire for culture change. Surveys demonstrated residents have more perceived stress from uncertainty than attending physicians (15.6 [5.0] vs. 19.0 [3.6], p < 0.05). Residents also had significantly higher symptoms of burnout than attending physicians (7.1 [2.9] vs. 4.9 [2.0], p < 0.05). Higher anxiety from uncertainty significantly correlated with perceiving the learning environment as more competitive and stressful (r = 0.51, p < 0.01) and increased symptoms of burnout (r = -0.41, p < 0.01). No significant correlations were noted between disclosure of uncertainty, gender, and years since graduating medical school. Conclusions: Uncertainty is rife in the academic inpatient medical setting, and is perceived and acted upon differently by resident and attending physicians. Perceptions and behavior in relation to uncertainty is influenced by the learning environment and the culture of medicine. It seems essential for the medical education system to develop strategies to embrace uncertainty to benefit physician wellness and promote high quality therapeutic relationships with patients.