Implicit expression of uncertainty – suggestion of an empirically derived framework

Abstract

Background: Uncertainty occurs in physicians' daily work in almost every clinical context and is also present in the clinical reasoning process. The way physicians communicate uncertainty in their thinking process during handoffs is crucial for patient safety because uncertainty has diverse effects on individuals involved in patient care. Dealing with uncertainty and expressing uncertainty are important processes in the development of professional identity of undergraduate medical students. Many studies focused on how to deal with uncertainty and whether uncertainty is explicitly expressed. Hardly any research has been done regarding implicit expression of uncertainty. Therefore, we studied the ways in which medical students in the role of beginning residents implicitly express uncertainty during simulated handoffs. Methods: Sixty-seven advanced undergraduate medical students participated in a simulated first day of residency including a consultation hour, a patient management phase with interprofessional interaction, and a patient handoff. We transcribed the videographed handoffs verbatim and extracted language with respect to expression of uncertainty using a grounded theory approach. Text sequences expressing patient related information were analyzed and coded with respect to language aspects which implicitly modified plain information with respect to increasing or decreasing uncertainty. Concepts and categories were developed and discussed until saturation of all aspects was reached. Results: We discovered a framework of implicit expressions of uncertainty regarding diagnostic and treatment-related decisions within four categories: "Statement", "Assessment", "Consideration", and "Implication". Each category was related to either the subcategory "Actions" or "Results" within the diagnostic or therapeutic decisions. Within each category and subcategory, we found a subset of expressions, which implicitly attenuated or strengthened plain information thereby increasing uncertainty or certainty, respectively. Language that implicitly attenuated plain information belonged to the categories questionable, incomplete, alterable, and unreliable while we could ascribe implicit strengtheners to the categories assertive, adequate, focused, and reliable. Conclusions: Our suggested framework of implicit expression of uncertainty may help to raise the awareness for expression of uncertainty in the clinical reasoning process and provide support for making uncertainty explicit in the teaching process. This may lead to more transparent communication processes among health care professionals and eventually to improved patient safety.

The ubiquity of uncertainty: a scoping review on how undergraduate health professions’ students engage with uncertainty

“…Learners also had opportunities to develop their capacity to manage uncertainty in other, more indirect ways, e.g., through problem-based learning (Maudsley et al 2008 ; Rowan et al 2008 ; Landeen et al 2013 ; Koh et al 2008 ) and simulation (Senette et al 2013 ; Gormley and Fenwick 2016 ; Bintley et al 2019 ; Gärtner et al 2020 ; Groot et al 2020 ; Jowsey et al 2020 ). With regards to the former, researchers recommended that sessions should be actively tutored, and cases not overtly scripted, to support learning around uncertainty (Landeen et al 2013 ; Biley and Smith 1999 ; Maudsley et al 2008 ).…”

Factors contributing to uncertainty in decision making and strategies to reduce this uncertainty in undergraduate medical students.

“…In case of an inability to detect the implicit uncertainty, it can result in faulty clinical reasoning, thus causing medical errors. 17 There is a lack of a structured format for oral case presentations, where feedback is usually unstructured, depending on the topic, personality of the teacher, time constraints and errors made by students. 18 It is suggested that explicit instructions be given to students for the desired format and expectations, combined with structured feedback; this will help students refine their knowledge and clinical reasoning on a daily basis.…”

Frequency of medical students' language expressing implicit uncertainty in simulated handovers

“…To analyse the students' expression of implicit uncertainty during patient handover, we used our previously developed empirically derived framework 12 based on data from our earlier 360-degree competence-based assessment. 17 The development of this framework was based on qualitative research tools, which enabled the detection of implicit linguistic expressions of uncertainty in the appropriate context for it to be valid.…”

“…The complete framework depicting the language of different categories and subcategories of attenuators and strengtheners is described elsewhere. 12 …”

“… 11 In a previous qualitative study, we developed a framework for the implicit expression of uncertainty from attenuators and strengtheners of information used in handovers during patient presentations. 12 If uncertainty is not explicitly expressed or implicit expression of uncertainty goes unnoticed, it can become a threat to clinical decisions and patient safety. Becoming aware of implicit expressions of uncertainty will enable physicians and medical students to make uncertainty explicit and address it appropriately in order to prevent patient harm.…”