From student to professional series post 1: Navigating uncertainty by moving from “black and white” to “grey”

Uncertainty is a fact of life

Ben Franklin was on the mark when he said that the only certain things in this world were death and taxes. Will it rain today? Will the bus be on time? are daily questions that do not have clear or certain answers, yet we make decisions despite the inherent uncertainty — I will bring my umbrella; I will leave 5 minutes early. We routinely navigate uncertainty in our lives.

Consider these examples:

Educational examples:

• In the classroom — something that worked last year might not work this year
• A potential strike might lead to unforeseen cancellations

Clinical examples:

• Unscheduled walk in appointments and emergencies
• Patients that don’t respond to treatment as expected

Research examples:

• Unexpected results could be difficult to explain
• Funding cuts affect research long-term plan

In the health sciences, where tolerance of uncertainty or ambiguity is recognized as a beneficial attribute for newly practising veterinarians and doctors,^[1] there is still a tendency to teach students that there is a "right answer" and that their job is to find it using scientific fact and evidence-based medicine.^[2] In fact, students admitted to health sciences programs often have a long academic history of being rewarded for knowing the right answer^[3] — which runs counter to the actual practice of medicine, in which students and health professionals make decisions every day despite a lack of reliable or adequate information.

The extremes 😳

While higher uncertainty tolerance has been linked with improved quality of patient care and physician mental health,^[4] having either extremely high or extremely low uncertainty tolerance brings both disadvantages and advantages to medical practice.^[5] An individual with low uncertainty tolerance generally considers uncertain situations as threatening and may seek to avoid or mitigate them, while an individual with high uncertainty tolerance considers uncertain situations as opportunities, and may seek them out.

A recent paper described an archetypal physician with extremely low uncertainty tolerance as one who is uncomfortable making treatment decisions in the face of uncertainty, but is more willing to reach out to colleagues for help. A physician with extremely high uncertainty tolerance^[6], on the other hand, may fail to collect adequate information before making decisions, but is more likely to discuss diagnostic or treatment uncertainty with patients. In either extreme, the patient suffers. Thus the question for medical educators appears not to be simply “how can we increase uncertainty tolerance in our students?” but rather “how can we help our students learn to navigate uncertainty?”^[7]

Shifting from “right answer” to navigating grey

There is a growing recognition that navigating uncertainty is of vital importance in the transition from “student” to “entry to practice professional” in clinical practice. There is also a growing body of literature on explicitly addressing ambiguity in health professions curricula. The change from "black and white" (right/wrong, gold standard/everything else) thinking to a more nuanced "grey" approach marks a major shift in learner mindset.

A recent review^[8] reported that many different types of educational interventions, including problem-based learning, the medical humanities^[9], simulation, and reflection, can provide students with practice in navigating uncertainty. Some of the most important things that teachers can do is simply to (a) acknowledge that uncertainty exists and (b) begin to dismantle the “culture of certainty” that exists in medicine.^[10]

Modelling how we, as experts, approach uncertainty could potentially be helpful as students develop their own strategies to navigate clinical decision making. In our classes, not knowing–even for the instructor–is seen as an opportunity to learn rather than a sign of weakness. Students in our classes, for example, have often commented on the novelty of a professor/expert saying “I don’t know” when trying to interpret changes in patient bloodwork. Students seem to appreciate the explicit introduction to ambiguity in a safe classroom environment.^[11] In class we can then explore the “I don’t know” by discussing (1) possible options that could explain the observed change, (2) if there was further testing we could consider that might help determine the reason for the change, or (3) if the change was something that we would not act on at this time but continue to monitor.

We also use “grey cases” in class–case studies that are deliberately designed to incorporate uncertainty (Stephens^[12]). In our case-based second year veterinary clinical pathology course, for example, this is a guiding principle in choosing or creating cases. We believe that although the more grey the case, the greater the opportunity for complex thought and learning, we gradually ramp up into the grey by scaffolding the complexity and ambiguity in the cases we use. Multiple different viewpoints add to the complexity and ambiguity of a clinical case as well, especially when different professions are working together in a health care environment. The cases and scenarios Sheryl uses in interprofessional education events, for example, are intentionally grey as are many of the instructions thus providing opportunities for learners to navigate and negotiate their way through the uncertainty.

Another approach we have investigated is “drawing” on the experience of the fine arts in teaching people how to observe. ^[13] "Slow looking" ^[14] and detailed observation are essential components of the fine arts, but the skill of observation is generally not taught explicitly in the health professions even though expert physicians and veterinarians need to be expert observers. When veterinary and medical students slow down and thoroughly observe, whether it be a work of art in the classroom or a patient in the exam room, they are learning to thoroughly collect information, which is a strategy that can help to mitigate ambiguity and avoid jumping to conclusions when making a diagnosis. ^[15] An important part of the "slow looking" exercise is sharing observations with a small group–this shows students that even though they are all looking at the same painting, they bring their own experiences and biases when they observe, and they don’t all see the same thing.

In summary

Uncertainty is part of life and clinical practice. Preparing to live and work in uncertain environments is also part of life. As we work towards dismantling the culture of certainty with our learners we can:

• Scaffold from “black and white” to “grey” in the cases learners work through
• Model navigating uncertainty by explaining your thought processes
• Practice slow looking
• Say “I don’t know” more often, and
• Learn to get comfortable in the swamp ourselves.

Other posts in Collaborative Practices Blog: Going further together

^[1] Competency-Based Veterinary Education: Part 1 - CBVE Framework. Washington, DC: Association of American Veterinary Medical Colleges. www.aavmc.org

Medical Council of Canada. Examination objectives overview: Scholar. https://mcc.ca/objectives/scholar/

^[2] Domen, R. E. The Ethics of Ambiguity: Rethinking the Role and Importance of Uncertainty in Medical Education and Practice. Acad Pathol 3, (2016).

^[3] Interestingly, professionals who quickly reduce uncertainty and speak with authority are often rewarded for this behaviour in practice as they were in their academic training. Hmmm…🤔

^[4] Hancock, J. & Mattick, K. Tolerance of ambiguity and psychological well-being in medical training: A systematic review. Medical Education vol. 54 125–137 (2020).

^[5] Reis-Dennis, S., Gerrity, M. S. & Geller, G. Tolerance for Uncertainty and Professional Development: a Normative Analysis. Journal of General Internal Medicine vol. 36 2408–2413 (2021).

^[6] i.e. A person who can live comfortably in uncertainty longer than most may not go digging for more information which may not result in the best patient care!

^[7] Hancock J & Mattick K. Increasing students’ tolerance of ambiguity: the need for caution. Academic Medicine 87, 834 (2012).

^[8] Patel, P., Hancock, J., Rogers, M. & Pollard, S. R. Improving uncertainty tolerance in medical students: A scoping review. Medical education vol. 56 1163–1173 (2022).

^[9] This term is used to describe visual arts, literature, drama being in the medical school curricula.

^[10] Stephens, G. C., Rees, C. E. & Lazarus, M. D. Exploring the impact of education on preclinical medical students’ tolerance of uncertainty: a qualitative longitudinal study. Advances in Health Sciences Education 26, 53–77 (2021); Simpkin, A. L. & Schwartzstein, R. M. Tolerating Uncertainty — The Next Medical Revolution? New England Journal of Medicine 375, 1713–1715 (2016).

^[11] Fernandez, N. J., Wagg, C. R. & Warren, A. L. Changes in student perceptions and study strategies over time in a veterinary clinical pathology course using case-based instruction. J Vet Med Educ 45, (2018). https://jvme.utpjournals.press/doi/10.3138/jvme.0317-038r

^[12] Stephens, G. C., Rees, C. E. & Lazarus, M. D. Exploring the impact of education on preclinical medical students’ tolerance of uncertainty: a qualitative longitudinal study. Advances in Health Sciences Education 26, 53–77 (2021).

^[13] Pun intended 😏 Fernandez, N. J. et al. Comparison of Fine Arts– and Pathology-Based Observational Skills Training for Veterinary Students Learning Cytology. J Vet Med Educ 49, 393–406 (2022). https://jvme.utpjournals.press/doi/10.3138/jvme-2020-0096

^[14] https://www.gse.harvard.edu/ideas/usable-knowledge/20/01/art-slow-looking-classroom

^[15] Premature closure is often identified as a source of clinical error.