Exploring Uncertainty Tolerance in Medical Students on Clinical Placements: A Longitudinal Qualitative Study

Introduction: Uncertainty Tolerance (UT), a construct describing how individuals respond to uncertainty in their cognition, emotion and behaviour, is considered highly relevant to healthcare practice(i, ii). Prior research draws links between healthcare providers’/students’ UT and healthcare related outcomes, notably impaired psychological wellbeing in both doctors and medical students(ii). Although debate continues as to whether UT is a static personality trait or modifiable state, the prevailing healthcare UT model suggests that various factors (so-called “moderators”) may impact individuals’ UT(i). Despite the negative outcomes associated with lower UT, little is understood about how medical students on clinical placements experience uncertainty. To address this gap, our research question was “How do medical students, in their clinical years, experience and manage (i.e. “tolerate”) uncertainty?” Methods: Through a social constructionist approach, we conducted a longitudinal qualitative study of medical students at an Australian medical school. Participants included students transitioning from preclinical years to clinical placements (n=23), and to practice (n=18). Data were collected across the 2020 academic year, with students completing reflective diary entries during semesters (n=229), and end of semester semi-structured interviews (n=39). Diary entries prompted students to describe and reflect on a scenario in which they felt certain, and one which they felt uncertain. Data were analysed by framework analysis, using an abductive approach based on the integrative model for UT as the theoretical lens(i) (i.e. oscillating between deductively applying the model to the data to identify uncertainty stimuli, moderators and responses, and inductively exploring UT theory within the context of medical students’ experiences). Results: Participants described a wide variety of uncertainty stimuli: Some related to clinical medicine (e.g. dilemmas of diagnosis and management where a single best approach was unclear), others extended to professional and personal uncertainties (e.g. uncertainty related to healthcare social structures, tensions between personal and professional identity, career progression, etc.). Multiple factors appeared to moderate students’ UT, including: People, past experiences, sense of purpose, personal characteristics, guiding clinical information, assessment, placement orientation and reflective learning. Interestingly, others sharing their own uncertainty was described by students as having a dominant beneficial impact on their UT. Responses were divided into those described in the moment of uncertainty, and those described upon reflection. In the moment, students described a range of responses across their cognition, emotion and behaviour from negative (e.g. helplessness, anxiety and avoidance), to positive (e.g. acceptance, interest and action); longitudinally, however, the dominant pattern across student data was negative responses in the moment. By contrast, responses on reflection were often positive, and included: Identifying learning opportunities, a sense of gratitude, and the development of resilience. Discussion and Conclusions: Our results extend the prevailing UT model in several ways. We have improved the definitional characteristics of the UT construct, particularly in relation to moderator classifications, and responses on reflection within a clinical learner population. Importantly, many identified moderators are modifiable (e.g. placement orientation) and applicable outside of this context (e.g. sense of purpose). Together, this suggests opportunities for educational interventions for fostering students UT. Whilst our aim was to explore medical students UT on clinical placements, students identified that reflective diary engagement served to moderate their own experiences of uncertainty, and suggests that reflective practices, themselves, may serve as effective educational interventions for learners UT development. In conclusion, UT in medical students is complex and extends beyond clinical uncertainties described in previous research. Reassuringly, this research supports UT as a modifiable state, with multiple avenues for educational intervention raised by this study. References: i. Hillen, M. A., Gutheil, C. M., Strout, T. D., & Smets, E. M. (2017). Tolerance of uncertainty: Conceptual analysis, integrative model, and implications for healthcare. Soc Sci & Med, 180, 62-75. ii. Strout, T. D., Hillen, M., Gutheil, C., Anderson, E., Hutchinson, R., Ward, H., et al. (2018). Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes. Patient Educ Couns, 101, 1518-1537.