#2 Uncertainty – That’s what one fears most
– Scoping review of uncertainty tolerance highlights why theory matters
Host: Lara Varpio
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Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56(12), 1163–1173. https://doi.org/10.1111/medu.14873
This paper gave me a strong reaction when I read it because I realized that the way this paper framed uncertainty was not aligned with the way I have been thinking about uncertainty. I wanted to have a conversation with you all about the role of uncertainty and uncertainty tolerance in clinical work and in health professions education. I want to see if I’m off base with my conceptualization of these phenomena. As the only non-clinically trained host on this podcast, I can understand why uncertainty and the tolerance of uncertainty is part of the competencies expected of clinicians. But I am wondering about what the role of uncertainty is for clinicians and what function we want uncertainty tolerance to serve.
The purpose of the study was divided into two. First, they wanted to identify the range and type of interventions that have been developed to support uncertainty tolerance in medical students. To do this, they are gonna do a scoping review. The second part of the purpose is to synthesize reported association between the interventions and uncertainty tolerance. To do that, they engaged in some deductive coding of the papers, using a model of uncertainty created by Hillen et al.
The authors conducted a scoping review and followed the processes laid out by Arksey and O’Malley and updated by Levac. They also followed the PRISMA guidelines extension for scoping reviews for guiding the reporting. These authors use the right literature and follow the 6 steps of the scoping review process beautifully. They:
- identified the research question
- identified relevant studies (using Medline, PsychINFO, Embase, and ERIC databases)
- they selected studies
- charted the data
- collated, summarized and reported the results and
- undertook consultation
Part of the scoping review process is to bring your findings and analysis to a group of people who can offer informed or special or some way important insights to the analysis. This is a group of people who are uniquely positioned to help you know if you’ve missed anything, or if there is a perspective that needs to be addressed, or offer advice that is meaningful to the interpretation of findings. In this study, the authors consulted with a medical student, a medical educator, and a clinician. Why are these individuals have an important perspective on uncertainty tolerance?
The first purpose of the paper was to assess the nature and extent of the literature available to identify the range of UME interventions that have been developed and evaluate their impact on UT. The authors’ first search identified 1384 papers after duplicates were removed. Once that corpus was screened against the inclusion and exclusion criteria, only 53 remained. They did full text review during which an additional 29 papers were reviewed. This left them with a corpus of 24 manuscripts for analysis.
In terms of the characteristics of these 24 studies, there is simply heterogeneity. Some interventions had 12 participants, another had 900. Some studied single year cohorts, others studied a mixture of years of training. Some were single point in time interventions, others were held across various times across undergraduate training. Some interventions were mandatory, others were voluntary. Some used PBL, others were in simulation settings, some were in medical humanities training, some used reflection, others were assessments.
The second purpose of the study which was to map the interventions into Hilen’s conptual framework of uncertainty tolerance.
Some background about Hilen’s model:
In 2017, a team of five researchers from Portland and Amsterdamn, led by Hilen, set out to do 2 things: 1) analyze the meaning of uncertainty tolerance as conceptualized by developers of uncertainty tolerance measures, and 2) develop an integrative conceptual model to guide future empirical research regarding the nature, causes, and effects of uncertainty tolerance. To build this model, the team analyzed the meaning of uncertainty tolerance as presented by developers of uncertainty tolerance measures. The evidence base behind the model they created was all about measuring UT. This then shapes the conceptual model developed. It is developed based on what can be measured – not all the other aspects of UT.
While that is an acceptable approach, it comes with consequences. It means that the model they generated is focused on the individual who experiences uncertainty and on that person’s reaction.
The model says that an individual’s uncertainty is the response to one of three principle sources: ambiguity (lack of reliable, credible, adequate information); probability (randomness of future outcomes); complexity (features of information that are beyond understanding). There are three reactions that uncertainty can have on the individual: emotional, cognitive or behavioral. Those reactions can be positive or negative.
In terms of the causes of uncertainty, none of the studies explicitly stated the source of uncertainty according to any theory or model so the author team had to make interpretations. They could only do that for 11 papers because there wasn’t enough details in the paper. For the 11 papers, uncertainty was caused by ambiguity in 8 papers, by probability in 4, and by complexity in 2. (note that some papers must have had 2 causes behind the uncertainty)
In terms of responses, 10 studies did not report students’ responses to uncertainty in enough detail for coding. And one offered so much qualitatively rich detail that they couldn’t reduce it to a binary – positive or negative reaction.
“Of the 13 manuscripts they coded, 12 had cognitive responses, 8 reported emotional responses, and 5 behavioral responses. All 13 studies reported positive responses to uncertainty, with four studies reporting a negative response in the emotional domain despite positive responses being reported in the cognitive and/or behavioral domain.”
This study is a clear illustration of the role that the selection of theory makes to the research you do. The theory used in this paper is based on the premise that reducing uncertainty is a sign of better or improved tolerance of uncertainty. This is a very quantitative way of conceptualizing uncertainty. It distills it down to quantifiable, observable measures.
A different theory would have us looking at these interventions in a really different way: a different theory, gives us different interpretations.
Key articles on scoping review methodology mentioned in the episode
- Arksey, H., & O*Malley, L. (u.å.). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 2005(8), 19–32. https://doi.org/1364557032000119616
- Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science, 5(1), 69. https://doi.org/10.1186/1748-5908-5-69
- Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., … Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine, 169(7), 467–473. https://doi.org/10.7326/M18-0850
More interested in uncertainty? Two other articles for another perspective
- Ilgen, J. S., Watsjold, B. K., & Regehr, G. (2022). Is uncertainty tolerance an epiphenomenon? Medical Education, 56(12), 1150–1152. https://doi.org/10.1111/medu.14938
- Ilgen, J. S., Teunissen, P. W., de Bruin, A. B. H., Bowen, J. L., & Regehr, G. (2021). Warning bells: How clinicians leverage their discomfort to manage moments of uncertainty. Medical Education, 55(2), 233–241. https://doi.org/10.1111/medu.14304
Thank you Magdalena for you comment and questions. We will make sure to reply in one of the upcoming episodes. The post positivism has rendered some questions.... :-)
Thank you very much for your discussion and all the joy you add to it! I have two questions If the authors would be clear in the paper about the orientation – post positivism, would it be ok to take the Hillen model which is “quantitative” in its roots? However, in that case scoping review is not consistent with post positivism orientation…