Abstract
Introduction
Uncertainty can be defined as the dynamic subjective perception of not knowing what to think, feel, or do. How medical students respond to uncertainty can shape their attitudes towards patients, their career paths, and their own wellbeing. Maladaptive responses to uncertainty may cause medical students to feel higher levels of stress and negatively impact their academic performance. Given this impact on students, learning to respond well to uncertainty is an important aspect of medical education. Current approaches to teaching about uncertainty may not be adequate to prepare medical students for the uncertainties they encounter in clinical practice. Teaching about uncertainty may be enhanced by a holistic understanding of how medical students experience uncertainty in context. This research aimed to conceptualise uncertainty in medical education, explore medical students’ perceptions of uncertainty, and develop a teaching intervention to help support medical students to learn to navigate uncertainty.
Methods
An interpretive perspective frames this multi-stage study that was informed by Social Cognitive Theory and structured using an Educational Design Research approach.
First, a scoping literature review was conducted to identify conceptual models of uncertainty in healthcare. Models identified from the literature were analysed with content and inductive data analysis methods to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers, and responses to uncertainty.
Second, results of the scoping review were used to construct a questionnaire to examine how medical students respond to and experience uncertainty. The questionnaire included 29 self-efficacy items. For each item, participants rated their confidence to respond to an uncertain situation using a scale from 0 to 100. Participants were also asked to provide written responses about what sources of uncertainty they had encountered in their education. The questionnaire was piloted, refined, and administered to medical students in their second, fourth, and sixth year of a Bachelor of Medicine and Bachelor of Surgery degree at the University of Otago. Self-efficacy data were analysed using exploratory factor analysis, descriptive statistics, and multiple linear regression. Written responses about sources of uncertainty were analysed using a reflexive thematic approach.
Third, a literature review was performed to analyse currently available uncertainty teaching approaches for medical students. Results of this literature review were combined with the findings from the analysis of the self-efficacy scores and written response data to inform the construction of a teaching intervention that was evaluated with a feasibility study in clinical learning environments with fourth-year medical students.
Results:
The scoping review produced a Framework of Uncertainty for Medical Education, which highlights sources, subjective influencers, and responses to uncertainty, and the dynamic relationship among these elements.
The questionnaire was completed by 495 participants (69% response rate). There was no statistically significant difference in perceived self-efficacy to respond to uncertainty when second year students were compared to fourth- and sixth-year students. Two student groups had significantly higher self-efficacy scores: male students and students who entered the degree programme with clinical or workplace experience. From the 465 participants who provided written responses about sources of uncertainty in their medical education, three sources of uncertainty were identified: insecurities about their own knowledge and capabilities, confusion about their role, and challenges navigating learning environments.
A teaching intervention, named The Uncertainty Prompts, was designed to enhance medical students’ self-efficacy to respond to uncertainty. The teaching intervention consists of statements that doctors can use to model constructive responses to uncertainty and invites students to share their own uncertainties. Evaluation findings from the feasibility study supported the proof of concept and revealed challenges to implementing The Uncertainty Prompts that included difficulties sustaining use of the prompts and a need to establish an educationally safe environment when discussing uncertainty.
Discussion and conclusion
This research provides educators with new perspectives on uncertainty in medical education. Using Social Cognitive Theory, medical students’ perceived self-efficacy to respond to situations of uncertainty was interpreted as unchanging as they progress through their education. Students’ experiences of uncertainty appear to be tied to how they see themselves, their role, and their learning environments. Uncertainty may therefore be linked to the developing professional identities of medical students. These findings suggest that uncertainty in medical education may be more dynamic and complex than previously conceptualised. Educators can use the Framework of Uncertainty for Medical Education to reflect on the complex nature of uncertainty in medical education and identify teaching strategies that support students to see uncertainty as a normal part of practice. The Uncertainty Prompts can be used to normalise the experience of uncertainty, and foster medical students’ perceived self-efficacy to respond to uncertainty. Evaluation findings about how The Uncertainty Prompts were used indicates that students and doctors welcome conversations about uncertainty, but may need explicit instruction to learn how to construct and maintain educationally safe environments that support and sustain the use of the intervention. Findings from the feasibility study have informed modifications to The Uncertainty Prompts in keeping with the iterative principles of Educational Design Research. In conclusion, this research provides educators with theoretical insights and practical contributions which enhance our understanding of how medical students experience uncertainty and our ability to support students to navigate this uncertainty.