Abstract:The practice of medicine involves inherent ambiguity, arising from limitations of knowledge, diagnostic problems, complexities of treatment and outcome and unpredictability of patient response. Research into doctors' tolerance of ambiguity is hampered by poor conceptual clarity and inadequate measurement scales. We aimed to create and pilot a measurement scale for tolerance of ambiguity in medical students and junior doctors that addresses the limitations of existing scales. After defining tolerance of ambiguity, scale items were generated by literature review and expert consultation. Feedback on the draft scale was sought and incorporated. 411 medical students and 75 Foundation doctors in Exeter, UK were asked to complete the scale. Psychometric analysis enabled further scale refinement and comparison of scale scores across subgroups. The pilot study achieved a 64% response rate. The final 29 item version of the Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD) scale had good internal reliability (Cronbach's alpha 0.80). Tolerance of ambiguity was higher in Foundation Year 2 doctors than first, third and fourth year medical students (-5.23,P = 0.012; -5.98, P = 0.013; -4.62, P = 0.035, for each year group respectively). The TAMSAD scale offers a valid and reliable alternative to existing scales. Further work is required in different settings and in longitudinal studies but this study offers intriguing provisional insights.Response to Reviewers: Dear Sir, Thank you for your email providing further feedback on our second draft manuscript.We have now responded to your comments (see table below).We have included a new manuscript both with and without tracked changes. In the tracked changes version we have accepted all format changes and so tracked changes indicate changes to text and tables.We look forward to hearing from you in due course. Yours faithfully, Powered by Editorial Manager® and ProduXion Manager® from Aries Systems CorporationJason Hancock (corresponding author) AbstractThe practice of medicine involves inherent ambiguity, arising from limitations of knowledge, diagnostic problems, complexities of treatment and outcome and unpredictability of patient response.Research into doctors' tolerance of ambiguity is hampered by poor conceptual clarity and inadequate measurement scales. We aimed to create and pilot a measurement scale for tolerance of ambiguity in medical students and junior doctors that addresses the limitations of existing scales. After defining tolerance of ambiguity, scale items were generated by literature review and expert consultation.

Context:The prevalence of stress, burnout and mental health disorders in medical students and doctors is high. It has been proposed that there may be an association between levels of tolerance of ambiguity (ie an ability to tolerate a lack of reliable, credible or adequate information) in clinical work and psychological well-being within this population. The aims of this systematic review were: (i) to assess the nature and extent of the literature available, in order to determine if there is an association, and (ii) to develop a conceptual model proposing possible mechanisms to underpin any association, in order to inform subsequent research. Methods: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched for articles published from inception to September 2018. Additional literature was identified by searching the reference lists of included articles, forward searches of included articles, hand searches of key journals and a grey literature search. Of the 671 studies identified, 11 met the inclusion criteria. A qualitative synthesis of included studies was performed.Results: All 11 included studies reported an association between a lower level of tolerance of ambiguity or uncertainty and reduced psychological well-being. Included studies were heterogeneous in terms of population and measurement approach, and were often of low methodological quality. Subsets of items from previously developed scales were often used without sufficient consideration of the impact of new combinations of items on scale validity. Similar scales were also scored inconsistently between studies, making comparison difficult.Conclusions: There appears to be an association between tolerance of ambiguity and psychological well-being. This provides new opportunities to understand and prevent the development of stress, burnout and mental health disorders in medical students and doctors. The conceptual model developed provides a framework for future research, which we hope will prevent wasted research effort through duplication and promote higher methodological quality.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Introduction: Uncertainty is an inevitable part of medical practice. An ability to tolerate uncertainty is viewed as a key competency across many health-care systems.Poor uncertainty tolerance (UT) has been linked to negative outcomes including reduced psychological well-being in medical students. A variety of medical education interventions have been developed with the intention of increasing medical students' UT. However, there is no synthesis of these studies available to inform education and research practice. Our aim was to conduct a scoping review of medical education interventions that evaluate their impact on UT.Methods: Medline, PsycInfo, Embase and ERIC databases were searched for articles published from inception to December 2020. An extensive supplementary search was conducted and both quantitative and qualitative evaluations were included. For each intervention, we categorised the stimulus of uncertainty (ambiguity, complexity and/or probability) and mapped the students' reported cognitive, behavioural, and/or emotional response(s) to uncertainty onto an existing conceptual framework.Results: Twenty-two of 24 included studies reported a positive impact on medical student UT in at least one domain (cognitive, behavioural or emotional). Interventions included problem based learning-based curricula, medical humanities, simulation, reflection and assessment. We found in four studies that a negative response in the emotional domain was reported despite positive responses also being reported in the cognitive and/or behavioural domains. Conclusion:We identified a range of medical education interventions which report a positive impact on medical student UT. Further research is required to understand why a single intervention may stimulate a negative emotional response alongside a positive cognitive or behavioural response. In turn, this could support stakeholders such as policymakers and institutions to adapt the medical curriculum to better prepare their medical students for practice by enhancing their UT.

(max 250 words)The ability to cope with ambiguity and feelings of uncertainty is an essential element of professional practice. Research with physicians has identified that intolerance of ambiguity or uncertainty is linked to stress 1,2 and some authors have hypothesised that there could be an association between intolerance of ambiguity and burnout (e.g. Cooke et al 2013 3 ). We describe the adaptation of the TAMSAD (Tolerance of Ambiguity in Medical Students and Doctors) scale 4 for use with veterinary students. Exploratory factor analysis supports a unidimensional structure for the Ambiguity tolerance construct. Although internal reliability of the 29 item TAMSAD scale is reasonable (α = 0.50), an alternative 27 item scale (drawn from the original 41 items used to develop TAMSAD) shows higher internal reliability for veterinary students (α = 0.67). We conclude that there is good evidence to support the validity of this latter TAVS (Tolerance of Ambiguity in Veterinary students) scale to study ambiguity tolerance in veterinary students.

Current guidelines suggest that educators in both medical and veterinary professions should do more to ensure that students can tolerate ambiguity. Designing curricula to achieve this requires the ability to measure and understand differences in ambiguity tolerance among and within professional groups. Although scales have been developed to measure tolerance of ambiguity in both medical and veterinary professions, no comparative studies have been reported. We compared the tolerance of ambiguity of medical and veterinary students, hypothesizing that veterinary students would have higher tolerance of ambiguity, given the greater patient diversity and less well-established evidence base underpinning practice. We conducted a secondary analysis of questionnaire data from first- to fourth-year medical and veterinary students. Tolerance of ambiguity scores were calculated and compared using the TAMSAD scale (29 items validated for the medical student population), the TAVS scale (27 items validated for the veterinary student population), and a scale comprising the 22 items common to both scales. Using the TAMSAD and TAVS scales, medical students had a significantly higher mean tolerance of ambiguity score than veterinary students (56.1 vs. 54.1, p<.001 and 60.4 vs. 58.5, p=.002, respectively) but no difference was seen when only the 22 shared items were compared (56.1 vs. 57.2, p=.513). The results do not support our hypothesis and highlight that different findings can result when different tools are used. Medical students may have slightly higher tolerance of ambiguity than veterinary students, although this depends on the scale used.