A typology of uncertainty derived from an analysis of critical incidents in medical residents: A mixed methods study

Abstract

BackgroundMedical uncertainty is inherently related to the practice of the physician and generally affects his or her patient care, job satisfaction, continuing education, as well as the overall goals of the health care system. In this paper, some new types of uncertainty, which extend existing typologies, are identified and the contexts and strategies to deal with them are studied.MethodsWe carried out a mixed-methods study, consisting of a qualitative and a quantitative phase. For the qualitative study, 128 residents reported critical incidents in their clinical practice and described how they coped with the uncertainty in the situation. Each critical incident was analyzed and the most salient situations, 45 in total, were retained. In the quantitative phase, a distinct group of 120 medical residents indicated for each of these situations whether they have been involved in the described situations and, if so, which coping strategy they applied. The analysis examines the relation between characteristics of the situation and the coping strategies.ResultsFrom the qualitative study, a new typology of uncertainty was derived which distinguishes between technical, conceptual, communicational, systemic, and ethical uncertainty. The quantitative analysis showed that, independently of the type of uncertainty, critical incidents are most frequently resolved by consulting senior physicians (49 % overall), which underscores the importance of the hierarchical relationships in the hospital. The insights gained by this study are combined into an integrative model of uncertainty in medical residencies, which combines the type and perceived level of uncertainty, the strategies employed to deal with it, and context elements such as the actors present in the situation. The model considers the final resolution at each of three levels: the patient, the health system, and the physician’s personal level.ConclusionsThis study gives insight into how medical residents make decisions under different types of uncertainty, giving account of the context in which the interactions take place and of the strategies used to resolve the incidents. These insights may guide the development of organizational policies that reduce uncertainty and stress in residents during their clinical training.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-015-0459-2) contains supplementary material, which is available to authorized users.

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“…According to the literature, optimal role-modelling means explicitly setting the rules about how hierarchical relationships operate in different environments and how trainees should expect to be embedded within them ( CMOC 14 in Part S5). 28 , 50 , 53 , 55 , 61 , 83 , 97 , 101–109 Conversely, role-modelling may result in the reinforcement of suboptimal prescribing habits and prescribing etiquette(s) if rules remain implicit or are only enforced through authority and the rationale is not clarified to facilitate learning ( CMOC 15 in Part S5). 27 , 28 , 50 , 53–55 , 64 , 77 , 84 , 97 , 109–113 Such hierarchical environments where the rationale for prescribing decisions is rarely discussed are often perceived to contribute to a culture of using doctors-in-training to provide service rather than prioritizing their learning needs ( CMOC 16 in Part S5).…”

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“…In his model, Beresford distinguished three issues of uncertainty, which he suggested affect decision‐making: technical uncertainty (ie, indeterminate data); conceptual uncertainty (ie, the misalignment between abstract criteria and real‐world problems); and personal uncertainty (ie, inadequate understanding of patient wishes) . Beresford's model was applied as a framework for subsequent studies . For example, in 2008, Farnan and colleagues investigated the experiences of uncertainty among medical residents, further qualifying the domains of Beresford's model to include transitions of care, diagnostic decision‐making, and management conflict (conceptual); procedural skills and knowledge of indications (technical); and goals of care (personal).…”

“…For example, in 2008, Farnan and colleagues investigated the experiences of uncertainty among medical residents, further qualifying the domains of Beresford's model to include transitions of care, diagnostic decision‐making, and management conflict (conceptual); procedural skills and knowledge of indications (technical); and goals of care (personal). In 2015, a mixed‐method study by Hamui‐Sutton and colleagues further developed Beresford's model to include five types of uncertainty, adding systematic and ethical uncertainty to technical, conceptual, and communication uncertainty (personal uncertainty in Beresford's work). Despite Beresford's early efforts to take into account a variety of healthcare settings, empirical work extending his model has been limited to the perspectives of medical residents .…”

“…In 2015, a mixed‐method study by Hamui‐Sutton and colleagues further developed Beresford's model to include five types of uncertainty, adding systematic and ethical uncertainty to technical, conceptual, and communication uncertainty (personal uncertainty in Beresford's work). Despite Beresford's early efforts to take into account a variety of healthcare settings, empirical work extending his model has been limited to the perspectives of medical residents . It is timely to reexamine a model of uncertainty that can take into account various healthcare domains, the range of professions, and different countries.…”

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“…Generally, medical trainees resolve medical uncertainty by consulting seniors through a predetermined hierarchy [ 39 ]. Farnan et al [ 2 ] reported that residents had managed uncertainty in critical incidents through a firm hierarchy, seeking help from colleagues and literature first, and then senior residents, specialty fellows, and the attending physician.…”