Appendix 2: Video 1.2 Transcript
Hello! My name is Georgina Stephens. I’m a medical doctor, anatomy educator, and health professions education researcher. I research how medical students and doctors experience and manage uncertainty. Although building and applying knowledge and evidence is a large part of the role of a health professional, managing uncertainty is now considered an important skill for health professions learners and graduates to develop.
When I reflect on my own experience as a medical student, I don’t think I really had any idea just how much of a role uncertainty would play in my career. As an early years student, I believed that if I studied hard enough, I would acquire enough knowledge to vanquish most of the uncertainty I faced. However, my beliefs about uncertainty changed significantly as I commenced clinical placements.
On the wards, there was very little I observed that seemed to reflect my textbook learning. Instead, I began to appreciate the uncertain reality of medical practice and that absolutely certain or correct approaches to patient care were almost the exception, as knowledge was applied relative to a particular patient and context. I also became increasingly aware of the gaps in the evidence base for medical practice and how this created grey areas in how to most effectively care for patients. Although I continued to learn certain ‘facts’ to pass my exams, these often seemed disconnected from my learning for the daily practice of medicine with its inherent uncertainties.
These experiences of uncertainty only expanded as I commenced practice. Junior doctors typically change roles every few months. With each new rotation, I’d feel an intense wave of uncertainty, and this pattern continued as I increased in seniority and took on greater responsibility for patient care. Even if I had the requisite knowledge and skills, there were some parts of my job that were just unknowable. For example, I could inform my patients of published figures about rates of adverse events for different treatments, but I couldn’t tell them if they would be among the 99 per cent who would be fine or the 1 per cent who would have a life-altering complication.
I also began to feel uncertain about my career direction, which was previously something I was very certain about. So, I decided to step away from the world of clinical medicine for a little while and took up a post teaching anatomy. It was during this role that I developed a love of teaching and became interested in researching how educators can effectively support students’ learning.
The first education research project I undertook explored how students develop their professional identity. Through interviews with students I learned that managing uncertainty was a huge part of the medical student experience and something that many struggled with. So, I delved into the literature on uncertainty and encountered the construct of uncertainty tolerance.
In particular, a colleague pointed us to a review paper from Hillen and colleagues published in 2017. They defined uncertainty tolerance as the set of negative and positive psychological responses – cognitive, emotional, and behavioural – provoked by the conscious awareness of ignorance about particular aspects of the world. The authors arrived at this definition after reviewing 18 different questionnaires or scales designed to measure whether somebody tends to respond more negatively to uncertainty, also known as uncertainty intolerance, or more positively.
I ultimately embarked on a PhD exploring how medical students experience uncertainty, and let me tell you, I had to really learn to manage uncertainty during this project. One of the major reasons for this was the many different ways in which this construct has been referred to by different researchers and disciplines over time.
Research on the general topic of uncertainty commenced in the mid-20th century with the work of Else Frenkel-Brunswik, who was a personality and social psychologist. She is acknowledged as the first researcher to describe ‘tolerance vs intolerance of ambiguity’. Ambiguity is a term that is widely used in research in this field but has been defined in different ways. It typically refers to the quality of having different possible meanings. Else Frenkel-Brunswik was researching personality and ethnic prejudice in children and teenagers. She noted that individuals who were intolerant of ambiguity tended to resort to black–white solutions and make premature judgements that they held on to even when presented with information to the contrary. In comparison, those who were tolerant of ambiguity could more easily accept the coexistence of contrasting perspectives.
Building on this research, Stanley Budner developed the seminal tolerance–intolerance of ambiguity scale, which was published in 1962. Budner describes that people who are more tolerant of ambiguity tend to perceive ambiguity as ‘desirable’ or opportune, whereas those who are intolerant of ambiguity tend to perceive ambiguous situations as ‘sources of threat’. Budner’s work seems like it set a trend for scale development that continues to the present day, with researchers still trying to create a scale which most effectively captures how people respond to ambiguity.
The term intolerance or tolerance of uncertainty was introduced relatively more recently and perhaps was initially more associated with psychological research into mental health disorders. It is unclear from my reading of the literature why uncertainty emerged as a separate term from ambiguity in this field, especially as discussions of ambiguous situations are often described in papers nominally focussed on uncertainty. As with tolerance of ambiguity, research into tolerance of uncertainty has also produced a variety of scales.
Even though some researchers prefer the term ambiguity and others uncertainty, the definitions used across the literature vary. This is why Hillen and colleagues embarked upon their review, with the aim of bringing some consistency to this important field of research. They analysed how authors defined terms relating to ambiguity, uncertainty, and tolerance and also evaluated meanings implicit within the questions asked in scales. What they found was that there were no clearly discernible differences between how terms such as tolerance of ambiguity and tolerance of uncertainty were used. So, in essence, tolerance of ambiguity and tolerance of uncertainty, as well as related terms such as stress or reactions to uncertainty, can broadly be considered synonymous. This unified definition of the construct has now served as the basis for several important reviews, including how uncertainty tolerance impacts healthcare outcomes.
My hope is that educators understand that building knowledge and developing learners’ skills for managing uncertainty go hand in hand, so that ultimately our future health professionals are better prepared for the uncertainties they will face in practice.
