Luther, Vera P. MD; Crandall, Sonia J. PhD, MS
Dr. Luther is assistant professor, Department of Internal Medicine, Section on Infectious Disease, and associate program director, Internal Medicine Residency Program, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Dr. Crandall is professor, Department of Family and Community Medicine, director of scholarship and research, Department of Physician Assistant Studies, and affiliate, Maya Angelou Center for Health Equity, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Correspondence should be addressed to Dr. Crandall, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157; e-mail: firstname.lastname@example.org.
Editor's Note: This is a commentary on Wayne S, Dellmore D, Serna L, Jerabek R, Timm C, Kalishman S. The association between intolerance of ambiguity and decline in medical students' attitudes toward the underserved. Acad Med. 2011;86:877–882.
Despite significant advances in scientific knowledge and technology, ambiguity and uncertainty are still intrinsic aspects of contemporary medicine. To practice confidently and competently, a physician must learn rational approaches to complex and ambiguous clinical scenarios and must possess a certain degree of tolerance of ambiguity. In this commentary, the authors discuss the role that ambiguity and uncertainty play in medicine and emphasize why openly addressing these topics in the formal medical education curriculum is critical. They discuss key points from original research by Wayne and colleagues and their implications for medical education. Finally, the authors offer recommendations for increasing medical student tolerance of ambiguity and uncertainty, including dedicating time to attend candidly to ambiguity and uncertainty as a formal part of every medical school curriculum.
Despite significant advances in scientific knowledge and technology, ambiguity and uncertainty are still intrinsic aspects of contemporary medicine. To practice confidently and competently, a physician must learn rational approaches to complex and ambiguous clinical scenarios and must possess a certain degree of tolerance toward ambiguity.
The Significance of Ambiguity and Uncertainty in Medicine
Ambiguity and uncertainty in medicine have similar meanings. Ambiguity has been described as inexactness or double meaning; uncertainty has been described as a fact or condition that lacks firm predictability.1 Ironically, although physicians must tolerate some degree of uncertainty and ambiguity, as these are ubiquitous elements of medical practice, the culture of medicine has little tolerance for ambiguity and uncertainty. Patients and physicians alike are relatively intolerant of physician uncertainty. We, as a society, expect that after a thorough subjective and objective assessment of the patient, a physician will be able to make an accurate diagnosis. The inability to make an accurate diagnosis after a thorough evaluation often will lead to frustration on both the part of the patient and the physician.
On one hand, the anxiety and frustration that even experienced physicians encounter when facing ambiguity and uncertainty may be constructive because it motivates physicians to continue to evaluate, ponder, and care for patients even when a diagnosis or positive outcome is not readily apparent. However, physicians who are relatively intolerant of ambiguity are more likely to experience a greater degree of frustration and anxiety, which may ultimately lead to disillusionment and even burnout.
Furthermore, a physician's tolerance of uncertainty influences his or her clinical practice. Physicians who are less tolerant of uncertainty on encountering ambiguous or complex clinical scenarios are more likely to order excessive diagnostic testing and additional empiric treatment regimens compared with physicians who are more tolerant of uncertainty. These extraneous interventions not only increase health care costs but also place patients at risk for experiencing adverse events from unnecessary tests and treatments.2,3 In addition, physicians who are less comfortable with uncertainty are less likely to discuss this uncertainty with their patients and are less likely to engage in shared decision making.4
Overview of Recent Research Outcomes
In this issue, Wayne and colleagues5 examined the association between intolerance of ambiguity as a relatively “fixed” trait and a decline in medical students' attitudes toward underserved and poor populations. The authors reviewed the research on the change in attitudes toward the underserved and on intolerance of ambiguity. In their study, medical students who were more intolerant of ambiguity, as demonstrated by higher scores on Budner's Intolerance of Ambiguity (IA) questionnaire, experienced significantly greater negative changes in attitudes toward the poor and underserved during medical school, as measured by the Medical Students' Attitudes Toward the Underserved (MSATU) questionnaire. Students who had high tolerance of ambiguity (lowest 20% of the IA scores) had a positive change in MSATU score “more than three times greater” than students who were intolerant of ambiguity (highest 80% of the IA scores). The authors also found that younger students and female students were less likely to report a decline in attitudes during medical school.5
Implications for Medical Education
Wayne and colleagues5 make a compelling argument that it is time to thoughtfully reexamine the concept of ambiguity in medicine as well as the anxiety it causes in medical students. The authors note that ambiguity by itself may not be problematic, but the reaction it produces may be detrimental and may suggest that medical educators are addressing the topic too generally.
We agree that this topic deserves special attention in medical education because it can cause significant anxiety, frustration, disillusionment, self-doubt, feelings of inadequacy (not being “good enough”), and insecurity regarding professional skill level.6 Further, intolerance of ambiguity and uncertainty may impact an individual's future career choice as medical students who are more intolerant are less likely to practice in primary care or resource-limited settings.6 Although students may learn some strategies for dealing with uncertainty in medicine as part of the “hidden curriculum” by observing their role models, there is a paucity of published literature that describes dedicated curricular initiatives to directly address ambiguity and the reactions that it causes.
Because of the negative reactions that ambiguity may cause (not being “good enough,” potentially influencing future career choice), medical educators should be more purposeful in discussing the inherent ambiguity and uncertainty of clinical care as well as the reactions that they produce. We are obligated to be more deliberate in our educational practice.
Recommendations for Improving Tolerance of Ambiguity and Uncertainty
Wayne and colleagues5 suggest that medical education should directly address the ambiguity inherent in medicine and the subsequent anxiety that it produces. They also suggest that students should receive specific education on the healing that can be done through acknowledgment and support rather than through a routine focus on “fixing” or “solving” complex problems.
We agree and suggest that, through self-reflection and improved patient-centered communication skills that cultivate relationship building, students can learn valuable mechanisms to cope with and convey uncertainty. Specifically, professionalism courses that include faculty-facilitated small-group discussions provide good venues for reminding students of their own humanity and help them learn to connect with the humanity we all share. These small-group courses easily lend themselves to discussions on the anxiety, frustration, and disillusionment that can result from ambiguity and uncertainty. However, it is essential to carry forward these professionalism ideals into the clinical years, when students face ambiguity and uncertainty in “real time,” so they can learn to incorporate coping and communication strategies into their daily practice. Frequent dialogues between students, residents, and faculty members to examine what students perceive as ambiguous situations will likely be valuable and should be a formal part of the clinical curriculum. Development programs to address the perceived needs of the faculty, to ensure that they are prepared to facilitate these discussions, will be beneficial as well.
Another technique for directly addressing the ambiguity and uncertainty inherent in medicine is to teach students about the fundamental nature of medicine. Schön,7 in Educating the Reflective Practitioner, describes professional practice as “high, hard ground overlooking a swamp.” For medicine, the high, hard ground is the scientific zone, which is fact based, predictable, and consists of solvable problems, whereas the artistic or indeterminate (messy) zone is characterized by uniqueness, conflict, and ambiguity.7 Physicians practice in the artistic zone often, and medical education curricula should acknowledge that some degree of anxiety is natural and predictable when operating in the artistic zone. We should strive to equip students with knowledge on how to act wisely in states of ambiguity and uncertainty.
In addition to purposeful discussions with clinical role models, reflective writing can be a valuable means to address ambiguity and uncertainty in medical education. For instance, Nevalainen and colleagues6 found that reflective writing exercises were an effective method for third-year medical students in their first clinical year to express and deal with clinical uncertainty as well as the difficult feelings that may accompany it. While participating in a yearlong elective course, students in the study described events and the feelings and thoughts evoked by those events. Interestingly, at the beginning, a majority of the students' writings focused on events that prompted thoughts and feelings of inadequacy (insecurity of professional skills, fear of making mistakes, coping with responsibility). However, at the end of the course, their comments expressed more self-tolerance of being “good enough to be a doctor.” Thus, if reflective writing exercises are formalized within a curriculum, the faculty should be prepared to deal attentively and empathically with students' thoughts and feelings of inadequacy to facilitate students' progress into being self-tolerant, self-accepting as “good enough,” and self-compassionate.
Ambiguity and uncertainty are inevitable aspects of medicine and can cause significant negative reactions in medical students. Addressing ambiguity and uncertainty is an important endeavor in medical education. We advocate that dedicating time to attend candidly to ambiguity and uncertainty should be a formal part of every medical school curriculum.
Other disclosures: None.
Ethical approval: Not applicable.
1 Dogra N, Giordano J, France N. Cultural diversity teaching and issues of uncertainty: The findings of a qualitative study. BMC Med Educ. 2007;7:8.
2 Carney PA, Yi JP, Abraham LA, et al. Reactions to uncertainty and the accuracy of diagnostic mammography. J Gen Intern Med. 2007;22:234–241.
3 Tubbs EP, Elrod JA, Flum DR. Risk taking and tolerance of uncertainty: Implications for surgeons. J Surg Res. 2006;131:1–6.
4 Politi MC, Légaré F. Physicians' reactions to uncertainty in the context of shared decision making. Patient Educ Couns. 2010;80:155–157.
5 Wayne S, Dellmore D, Serna L, Jerabek R, Timm C, Kalishman S. The association between intolerance of ambiguity and decline in medical students' attitudes toward the underserved. Acad Med. 2011;86:877–882.
6 Nevalainen MK, Mantyranta T, Pitkala KH. Facing uncertainty as a medical student—A qualitative study of their reflective learning diaries and writings on specific themes during the first clinical year. Patient Educ Couns. 2010;78:218–223.
7 Schön DA. Educating the Reflective Practitioner. San Francisco, Calif: Jossey-Bass, Inc.; 1987.