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Tolerance for Ambiguity

An Ethics-Based Criterion for Medical Student Selection

Geller, Gail ScD, MHS

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doi: 10.1097/ACM.0b013e31828a4b8e
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Several years ago, I coordinated the ethics course that was required for first-year medical students at my institution, the Johns Hopkins School of Medicine. I was keenly aware of significant differences in students’ reactions to the course. Some students were excited and stimulated at the prospect of debating issues and ideas that were complex and ambiguous, whereas others were palpably anxious at the prospect of being graded in a subject that did not have “right” and “wrong” answers. Intrigued by what I noted as variability in students’ tolerance for ambiguity, I searched for and discovered a substantial social science literature on this topic. This experience inspired me to pursue a career at the intersection of medical sociology and ethics, with a particular interest in the impact of ambiguity on medical students and medical education.1 I now oversee the social, behavioral, and ethical components of the medical curriculum at the same institution and observe similar variability in students’ tolerance for ambiguity. The way students respond to uncertainty in medicine deserves heightened attention in light of imminent changes to the medical student selection process, which motivated me to write this Perspective.

Impending Changes to the Medical School Admission Process

For the last decade, the Association of American Medical Colleges has been interested in and committed to transforming the medical school admission process. The goal is to enable the assessment of humanistic characteristics and, thus, to select students who are more likely to become physicians who can communicate and relate with patients and engage in ethical decision making. Recently, the decision was made to revise the MCAT exam to include more social and behavioral science and to adjust the prerequisite course requirements for admission to medical school.2 These changes will be implemented in 2015. Identifying prospective physicians who possess humanistic and communication skills is an important goal, but the imminent changes to the admission process may not be sufficient to evaluate key personality traits that lend themselves to the well-rounded, thoughtful, empathic, and respectful physicians we all hope to have.

I propose that consideration be given to assessing prospective students’ tolerance for ambiguity as part of the admission criteria. Given the inherent ambiguities in medical care and the evidence that ambiguity tolerance is a meaningful characteristic for medical students, it is well worth exploring what the implications would be. And with the revision of the medical admission process already under way, the time is ripe.

The Concept of Tolerance for Ambiguity

In the past several years, there has been extensive scholarship on the impact of ambiguity and uncertainty on medical education and medical care. Although these concepts are related and have been used interchangeably, ambiguity and uncertainty are not equivalent.3,4 Ellsberg5 writes that both are types of “risk,” but they vary in probability: In a case of uncertainty, the probability of a particular outcome is known; with ambiguity, the probability is unknown. Grenier et al3 propose a time-oriented distinction, with uncertainty relating to an event in the future and ambiguity concerning circumstances in the present. In this light, “ambiguous” situations have either more shades of gray or greater urgency and may, thus, require more tolerance.

It is also important to note the recent literature on ambiguity aversion and its adverse consequences in both medical practice6 and clinical research.7 The negative effects of ambiguity aversion are crucial to understanding the benefits at the other end of the spectrum: tolerance of ambiguity.

Intolerance of ambiguity, or aversion to ambiguity, was first identified more than 50 years ago.8 It was described as a personality characteristic in which situations that are “novel, complex or insoluble” are perceived as “sources of threat.”9 To the degree that medicine and health care are characterized by novelty, complexity, and sometimes insolubility, it is extremely important to understand how clinicians react to such circumstances. In general, individuals with high ambiguity tolerance are drawn to or captivated by the unknown. By contrast, those with low tolerance tend to deny, avoid, or minimize ambiguity, and experience significant stress when faced with it.9 Ambiguity intolerance has been associated with other personality traits such as authoritarianism, dogmatism, rigidity, conformity, and ethnic prejudice.9,10 Clearly, these traits contradict the humanistic, culturally competent, and patient-centered qualities underlying ethical medical practice.

Tolerance for Ambiguity in Medical Practice and Education

In medical practice, an individual’s low tolerance for ambiguity has been associated with a biomedical rather than a biopsychosocial worldview,11 as well as increased test-ordering tendencies and failure to comply with evidence-based guidelines,12 greater likelihood of recalling screening mammograms,13 increases in patient charges,14 withholding negative genetic test results,15 fear of malpractice litigation and defensive practice,16 and discomfort in the context of death and grief.17,18

Tolerance for ambiguity also exerts a powerful influence on the attitudes and behaviors of medical students. Numerous studies have measured students’ levels of ambiguity tolerance1,19–21 and correlated their scores with a range of sociodemographic and behavioral characteristics.19–26 This evidence suggests that higher tolerance for ambiguity is associated with students’ leadership ability25 and their willingness to practice in rural areas.26 Conversely, there is a strong relationship between students’ low tolerance for ambiguity and their fears of making mistakes,22 their negative attitudes toward the underserved,23,24 and bias against those who abuse alcohol.1 It remains unclear whether tolerance of ambiguity is linked to students’ specialty choices. In some studies, there was no association.20,21 In others, specialties that require high levels of precision, such as surgery, tended to attract individuals with low ambiguity tolerance. Conversely, specialties that are inherently ambiguous, such as psychiatry, appealed to individuals with higher tolerance.1

Despite its importance, tolerance for ambiguity has been overlooked both in the selection and also the training of medical students.27–30 Sociologists of medicine have long observed that the medical education process rewards certainty.27,28 In recognition that ambiguity and uncertainty have been neglected in the culture of medicine, there have been recent proposals to acknowledge, embrace, and explicitly cultivate ambiguity tolerance in the medical curricula.29,30 This is undoubtedly a laudable goal, but it assumes that ambiguity tolerance can be taught. Although evidence among residents suggests that ambiguity tolerance can improve over time and with experience,31 this question has not been explored among medical students. Studies of ambiguity tolerance in medical education have been cross-sectional, not prospective. Although some studies have compared several cohorts of students, they have not been able to determine whether ambiguity tolerance changes over time and in response to various forces.26 The degree to which this characteristic is stable or malleable will determine whether it can be taught and nurtured.

One testable hypothesis is that tolerance for ambiguity is both a personality trait and a temporal state. As is true of most behavioral and personality traits, the “phenotype,” or expressed characteristic, is likely to reflect a complex combination of inherited susceptibility and environmental influences. In other words, individuals in general, and applicants to medical school in particular, arguably possess a predisposition to respond to ambiguity in a particular way, a response mitigated or reinforced by life experience. In the specific case of ambiguity tolerance among medical students, there may be an interaction between students’ tolerance and their stage in the training process. Undoubtedly, students entering medical school vary in their tolerance for ambiguity. However, the medical socialization process is likely to exert a mediating influence on how graduating students deal with ambiguity.

Based on the conceptual literature, a reasonable hypothesis is that students who enter medical school with high tolerance for ambiguity are drawn to, and stimulated by, the uncertainties that characterize medicine and patient care. As a result, they have many opportunities to hone their communication and decision-making skills in the face of ambiguity. By developing greater self-efficacy in such circumstances, as training progresses, a positive feedback loop results in which students’ tolerance for ambiguity increases. By contrast, students who enter medical school with low tolerance for ambiguity may be more likely to avoid, minimize, or negate the uncertainties that characterize medicine and patient care. Such coping strategies may result in a negative feedback loop in which students feel less competent under ambiguous circumstances and become even less tolerant. See Figure 1 for a graphical presentation of this hypothesis.

Figure 1:
A hypothesis regarding the interaction between levels of tolerance for ambiguity and levels of training. On the basis of the conceptual literature, it is reasonable to think that students who enter medical school with high tolerance for ambiguity are drawn to, and stimulated by, the uncertainties that characterize medicine and patient care. As a result, they have many opportunities to hone their communication and decision-making skills in the face of ambiguity. By developing greater self-efficacy in such circumstances, as training progresses, a positive feedback loop results in which students’ tolerance for ambiguity increases. By contrast, students who enter medical school with low tolerance for ambiguity may be more likely to avoid, minimize, or negate the uncertainties that characterize medicine and patient care. Such coping strategies may result in a negative feedback loop in which students feel less competent under ambiguous circumstances and become even less tolerant.

A Timely Proposal

At this time of transformation in the admission process and its criteria, and in conjunction with the planned changes to the MCAT exam and premedical course requirements, I propose that serious consideration be given to incorporating an assessment of ambiguity tolerance into the medical school admission process and evaluating its impact—both in the short and long term. Adopting this “call to action” would require a plan for assessing ambiguity tolerance and a determination of outcomes to be measured. The assessment plan could consist of quantitative strategies, qualitative strategies, or a combination of both. With respect to quantitative strategies, a number of validated scales exist1,3,6,9,10,32,33 that could be used or adapted for use in the medical admission process. The selected evaluative tool could be incorporated into the required application packet for prospective students. In the early stages of evaluation, students who were admitted into medical school on the basis of the well-established criteria would simply be reassessed at different intervals to determine whether their tolerance for ambiguity changes over the course of medical education. If, as hypothesized above, we find that the medical socialization process exerts a differential effect on students depending on their baseline tolerance for ambiguity, this evidence would lend support to including an assessment of tolerance for ambiguity as part of the admission criteria. This can be accomplished a few ways. Among students who otherwise meet the academic criteria for admission, one option would be to offer interviews only to those whose tolerance scores exceed a certain cutoff. An alternative strategy would be to offer interviews to all students who meet the academic standards for admission and, during the interview, use the tolerance scores to explore, qualitatively, students’ own assessments of their tolerance for ambiguity. Only those students whose responses reflect a certain depth of self-awareness would be offered admission.

The revisions planned for the medical school admission process have far-reaching potential to change the face of the medical profession in the future. This is an opportune time to consider and evaluate various ways of improving the culture of medical education and the assessment of prospective students. There are already significant culture changes under way in medical education, such as the growing emphasis on team care and interprofessional education. These changes may require greater tolerance for ambiguity among students because, occasionally, members of the team will disagree. Although students are being taught to “respect” their colleagues’ opinions (i.e., listen openly and not criticize), they may not be comfortable tolerating the ambiguity inherent in group decision making.

Admittedly, there are a number of student characteristics besides tolerance of ambiguity that might be worthy of assessing, and deciding which measures have the greatest relevance in the medical school admission process is daunting. Furthermore, it is not known whether any standardized measures are capable of determining the emotional and moral capacities of future physicians. We can shed light on this question by exploring the associations between test scores on the new MCAT exam and scores on other validated assessments of those personality traits that are critical to being a skilled, ethical physician.

A substantial body of literature suggests that tolerance for ambiguity is an important characteristic in medicine and that assessing and evaluating it among students is a good place to start. This evidence suggests that if medical schools admitted students who possess a high tolerance for ambiguity, quality of care in ambiguous conditions might improve, imbalances in physician supply and practice patterns might be reduced, the humility necessary for moral character formation might be enhanced, and the increasing ambiguity in medical practice might be better acknowledged and accepted. Now is the opportunity—when the time for change has already been acknowledged—to supplement and complement revisions to the MCAT exam by incorporating an assessment of ambiguity tolerance into the application process and, ultimately, perhaps into the selection process itself. Simultaneously, serious attention should be given to modifying the undergraduate premedical experience by incorporating innovative educational interventions designed to cultivate tolerance for ambiguity among prospective medical school applicants.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.


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