Uncertainty isn’t a bad word: Understanding its role in healthcare education

Australian universities are called to help prepare students for their future careers. This role requires that educators teach both discipline knowledge, and foster the development of workplace skills.

One skill at the forefront and intersection of both life and careers is uncertainty tolerance. Our own research, alongside others, is highlighting that uncertainty tolerance, or how someone perceives and responds to uncertain stimuli, is an essential workplace skill in nearly every industry.

A globally shared source or “stimulus” of uncertainty that has underscored the value of uncertainty tolerance is COVID-19 pandemic. From government and business, to education and healthcare, managing uncertainty is a key attribute for workers during the pandemic.

For healthcare workers in particular, even outside of the pandemic context, managing uncertainty is a daily reality. Accordingly, uncertainty tolerance is increasingly recognised as a necessary attribute for health professions’ graduates.

The human element

Despite media portrayals of “certainty” in healthcare, where a “correct” diagnosis is often arrived at within the span of a television episode, the reality is that healthcare practice is often ambiguous, complex and unpredictable. This is largely because of the variability of the human condition.

Individually, we’re unique in our biology, and how we think, feel and interact with the world. These differences from person to person also act as a dominant source of healthcare uncertainty.

Considering the healthcare context as a whole, sources of uncertainty are plentiful. It may stem from:

• factors related to a patient (for example, variability in how conditions present inconclusive test results, and unpredictable treatment outcomes)
• the relationship between the patient and their clinician (for example, communication across cultures)
• from broader system factors (such as ambiguity in the roles of different healthcare professionals working in a team, and institutional protocols that don’t align with the needs of an individual patient).

In summary, the “humanness” of healthcare means uncertainty is intrinsic to healthcare practice, and cannot be simply eliminated (and arguably, should not be attempted).

For effective clinical practice, which embraces the variabilities of the human condition and patient-centred care, healthcare uncertainty needs to be managed. Indeed, those with a higher tolerance of uncertainty may be more open to working with underserved patient populations and more likely to involve patients in shared medical decision-making.

Furthermore, future doctors who understand that uncertainty is intrinsic to healthcare may have enhanced psychological wellbeing.

Collectively, uncertainty tolerance may impact how healthcare providers treat and manage patients both from a biological (that is, illness diagnosis and management) and a socio-cultural perspective (how healthcare providers interact and engage with patients).

Healthcare education and uncertainty tolerance

The awareness that uncertainty tolerance is central in healthcare practice has led to an increasing number of healthcare programs listing uncertainty tolerance as a graduation competency, and many recommending assessing uncertainty tolerance for admissions into healthcare schools.

In the United States, medical schools are now monitoring uncertainty tolerance scores for benchmarking healthcare education programs.

What these initiatives have in common is the reliance on an effective measure of healthcare students’ uncertainty tolerance.

We set out to explore whether the existing healthcare-related uncertainty tolerance measures did, indeed, meet this need.

Our comprehensive systematic review and meta-analysis yielded field-changing results. While these scales may be adequate for measuring experienced doctors’ uncertainty tolerance, they were significantly less reliable when used to measure students’ uncertainty tolerance.

Despite more than half a century of research relating to these scales, and current engagement of these scales by peak bodies in undergraduate medical education, our work revealed that uncertainty tolerance scales lacked sufficient evidence for use in situations where the stakes are high for either population (students or doctors), but particularly in medical student populations.

This means that these scales are unsuitable for use in medical school admissions processes, or as part of student assessment, despite calls to do just that.

Further, we identified that few had tested these scales in other health profession contexts (such as nursing, physiotherapy, radiography etc.), despite uncertainty tolerance being listed as a graduate attribute across diverse health professions.

The desire to measure healthcare students’ uncertainty tolerance continues, and the value of being able to do this is very clear.

What was less clear is how healthcare students actually perceive and experience uncertainty during their healthcare educational journey, and whether this differs from practising doctors’ perceptions of uncertainty. By improving our understanding of the student experience, we may be able to enhance our teaching practices to support students’ development of uncertainty tolerance, and maybe develop a reliable and valid uncertainty tolerance scale targeting this student population.

How do medical students’ experiences of uncertainty differ from doctors?

Through a series of longitudinal, qualitative studies over a series of years, we asked:

How do medical students experience uncertainty across their degree course?

We found that during pre-clinical years, stimuli of uncertainty include the sheer breadth of knowledge expected of a novice medical student, and the differences between textbook knowledge and its application to real-world clinical problems.

In the clinical years, these stimuli of uncertainty further expanded into areas related to:

• how to effectively learn within the healthcare environment
• how to balance who the students are as individuals with who they are as developing healthcare professionals
• how to manage the uncertainty in patient care.

Essentially, we found that sources of medical student uncertainty appear to be much broader than those reported for doctors.

Medical students are experiencing the patient care uncertainties that doctors are managing, but as students are also managing uncertainties related to their learning and their career journeys.

Now that we had some insights into what students perceive as uncertain, we wondered what steps we (as educators) could take to help students learn to manage (that is, tolerate) these uncertainties to help them prepare for the ubiquitous uncertainties of their future work.

How can educators help students’ UT development?

It turns out that the ways in which educators can help students develop their uncertainty tolerance wasn’t well-known.

Interestingly, the areas where university funding cuts were greatest (the humanities and social sciences – HASS) are probably the most experienced at fostering uncertainty tolerance in the classroom.

We therefore set out to explore and build on HASS educators’ teaching practices that foster uncertainty tolerance in an effort to provide a framework for other educators to adapt to their disciplines.

This work highlighted that the educator plays a key role in fostering, or hindering, learners’ uncertainty tolerance development.

Educators can help build students’ uncertainty tolerance (the capacity to adaptively respond to uncertainty) by conveying to students their own struggles with managing prior uncertainties.

Known as “intellectual candour”, this approach can help students acknowledge that uncertainty is an experience we all share, and illustrates to students that it’s possible to move forward despite uncertainty.

By way of contrast, educators appear to hinder learners’ uncertainty tolerance development when they lecture students about knowledge in black-and-white terms, instead of engaging students in a dialogue about the limitations and complexities underpinning the information presented.

Our study also revealed that teaching practices (that is “moderators” of learner uncertainty tolerance) appear to “interact” with each other, and don’t necessarily act in isolation.

For instance, an educator may need to lecture some content to students, particularly when “scaffolding” knowledge in new content areas. Given lecturing is not typically ideal for fostering learner uncertainty tolerance (on its own), the educator may choose to deliberately introduce other teaching practices that foster learner uncertainty tolerance to “balance” this didactic teaching.

For example, building on lecture knowledge, educators may introduce real-world cases that help illustrate that the application of lectured knowledge to practice can be both complex and ambiguous, and have students work through these cases in diverse teams.

The ambiguous case becomes the educational stimulus of uncertainty, and our research suggests that the diverse teamwork moderates learner uncertainty tolerance more towards the “tolerant” end of the spectrum.

Our collective works, alongside the broader literature, illustrate that medical students experience a wide range of uncertainty stimuli, and that medical educators are well-placed to help these students learn to effectively manage uncertainties through their teaching practices.

Existing measures of learner uncertainty tolerance have significant limitations; thus, future work will need to explore whether objectively measuring learner uncertainty tolerance is possible.