Chapter 19: Moving Forward in Uncertainty

Taking the first steps along the path of teaching to support health professions learners’ uncertainty tolerance development can be a huge stimulus of uncertainty for educators. As educators learn more about the nature of uncertainty in healthcare and the wide variety of factors, or moderators, that can influence experiences of uncertainty, it can be difficult to see what is truly certain in the world – particularly when humans are involved. What we can be certain about, however, is the enduring presence of uncertainty in healthcare and, therefore, the imperative to help learners prepare to face their own uncertain journeys.

In this handbook, we have explored how uncertainty can arise in health professions education, sometimes within and sometimes beyond the control of educators. We have seen how learning activities such as grey cases, exploring multifaceted perspectives, and transferring learning can provide purposeful opportunities for learners to develop skills for managing uncertainty (Chapter 4). The challenge for educators isn’t simply to ensure their teaching activities stimulate uncertainty; in addition, it is to understand where best to introduce uncertainty within and across learning activities and along each learner’s journey.

By considering learner-, educator-, and system-sourced moderators of uncertainty (Chapter 5), educators can begin to anticipate learners’ responses to uncertainty and therefore to respond to their needs, such as identifying when they may need greater support, or indeed a greater challenge, to develop their skills for managing uncertainty. Assessment approaches such as authentic and programmatic assessment (Chapter 6) can then be used to evaluate skills for managing uncertainty, and feedback for learning becomes an integral component in ensuring learners understand how they are progressing with developing these skills. Critically, preparing learners to manage uncertainty does not need to occur separately from teaching foundational discipline knowledge, professional attributes, or clinical skills: the uncertain boundaries of topics are ideal spaces to demonstrate to learners that there can be limitations to even widely accepted facts (Stephens & Lazarus, 2024).

To move forward in uncertainty tolerance teaching practices, including where evidence is being built, educators can also draw from learning theories applicable to a variety of learners and contexts (Chapter 7). The relevance of learning theories such as experiential learning, transformative learning, and threshold concepts is emphasised by the presence of learner discomfort or uncertainty within these theories. Common to these theories are learner encounters with challenges or gaps in their learning and opportunities to change their understanding, through critical reflection, new experiences, and often a degree of struggle. As the influence of such learning theories has grown in contemporary higher-education learning environments and teaching practices, many educators have already begun implicitly teaching in ways that help support learners’ development of uncertainty tolerance (Lazarus et al., 2024).

This handbook encourages and challenges health professions educators to be more reflective in their teaching practices in relation to uncertainty. Educators’ reflective practice can include identifying existing ways in which they stimulate and moderate uncertainty and how they may more effectively prepare health professions learners for uncertainty, through purposeful development, adjustment, or evolution of their teaching practices. In this process, educators will undoubtedly encounter different sources of uncertainty, so it is important for them to be able to select the appropriate strategy for managing each uncertainty.

In Chapter 3, we describe a spectrum of uncertainty sources ranging from simpler uncertainty to more complex, or irreducible, uncertainty. These sources of uncertainty can create challenges or problems that we need to solve. Problems stemming from simpler sources of uncertainty typically require the expertise of only a single discipline. Such problems are more likely to have predictable and quantifiable outcomes. An example of a simple educational problem might be an educator seeking to identify effective teaching strategies for supporting learners’ anatomy knowledge. The educator can use applied science (also known as normal science), omitting human values by studying the context more objectively. In this case, studying the local learner population might reveal that exam performance improves with spaced repetition of quizzes. By gathering data through this objective, positivist approach using the scientific method, the educator can develop a fit-for-purpose solution.

As problems become more complex, the solutions become less clear, and expertise from more disciplines may be required to address the uncertainty. An example of a complex problem might be an effort to integrate uncertainty tolerance teaching practices in health professions education around the globe given its ubiquitous relevancy. This would require input from an expanded and diverse group of people: reliance on just a few ‘experts’ (e.g., the authors of this handbook) would not suffice; for example, a small group would lack local knowledge of most regions, and their knowledge of all the disciplines included in health professions education would be too limited. In such circumstances, an ideal approach would be to use post-normal science (Lazarus & Funtowicz, 2023), in which expertise comes from extended peer communities, and solutions need to be adaptable, because they are executed in complex and changing environments. Instead of aiming for a single best approach for integrating uncertainty tolerance globally, educators need to consider the values and experiences of their local communities. This may involve trying out solutions to a problem that may work within local factors (e.g., funding, space, staffing) and revisiting solutions later, when local factors change to reconsider their applicability. When faced with challenges or problems due to uncertainty, consider engaging in reflective practice that considers the complexity of the problem, and hence whether normal or post-normal scientific approaches may be most helpful.

Machine learning and artificial intelligence are increasingly touted for their ability to address healthcare challenges, including those stemming from uncertainty. Although generative artificial intelligence is often portrayed and interpreted as being more objective and certain than humans, current evidence suggests that known failings or errors of humans, such as our capacity for prejudice and discrimination, are also demonstrated by some artificial intelligence applications, due to the human-created materials they are trained on (Gebru, 2020). For now, the capacity for adaptively managing uncertainty remains primarily in the human sphere. Furthermore, the counter to automation bias – where humans avoid uncertainty and defer decision making to artificial intelligence – may simply be an appropriately developed capacity to tolerate uncertainty (Abdelwanis et al., 2024).

Although we cannot predict the future with any certainty, there are directions in which the field of uncertainty tolerance pedagogy may continue to grow, including priority areas for ongoing research. We are already seeing the evolution of higher education to support the development of artificial intelligence literacy. As artificial intelligence is increasingly integrated within health professions education and healthcare practice (Gordon et al., 2024), there may need to be even greater emphasis on developing health professions learners for managing uncertainty in a manner that supports person-centred care. Given the limitations to the evidence for assessing skills for managing uncertainty, research on this topic should be a priority. Rather than relying on uncertainty tolerance scales, which predominantly evaluate and focus on stress responses and have substantial limitations in their validity evidence for health professions learners (Stephens et al., 2022; Stephens et al., 2023), we advocate developing an assessment strategy which incorporates uncertainty through authentic and programmatic assessment approaches (Chapter 7). The evidence base for uncertainty tolerance teaching practices is still heavily weighted towards medicine and the global north (Moffett et al., 2021; Stephens et al., 2022), leaving opportunities for further research into health professions learners’ and educators’ experiences of uncertainty across professions, career stages, and contexts.

We encourage researchers to base future research in a conceptual framework, such as the model presented in Chapter 3, and to adapt this as evidence is identified that supports, refutes, or evolves the model. Perhaps the responses element of the model – and understanding characteristics of responses that represent adaptive or effective management of uncertainty in different contexts (Stephens et al., 2024) – is the aspect with the greatest potential for further research. Such knowledge could help inform the development of new uncertainty tolerance scales that move beyond a focus on stress and anxiety as key markers of lower uncertainty tolerance.

While this handbook focusses on uncertainty in healthcare, the need to manage uncertainty is increasingly relevant to all individuals’ professional and personal lives. Pressing examples of global uncertainties include those posed by climate change and increasingly polarised political movements. There is evidence that building learners’ uncertainty tolerance can also increase their capacity for social justice (Lazarus et al., 2023; Lazarus et al., in press) and person-centred care (Truong et al., 2022; Chapter 2).

We call on the readers of this handbook to become ambassadors for, and explorers of, teaching practices that best prepare health professions learners for uncertainty. While the journey into uncertainty tolerance teaching practices can itself be uncertain, we have experienced through writing this handbook with our 18 co-authors, that there are others keen to go on the journey. The journey into uncertainty starts with a single step, so we sign off by asking you to consider, what will that step be for you today?

References

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Gebru, T. (2020). Race and gender. In M. D. Dubber, F. Pasquale, & S. Das (Eds.), The Oxford handbook of ethics of AI (pp. 252–269). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780190067397.013.16

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Lazarus, M. D., & Funtowicz, S. (2023). Learning together: Facing the challenges of sustainability transitions by engaging uncertainty tolerance and post-normal science. Sustainable Earth Reviews, 6, Article 18. https://doi.org/10.1186/s42055-023-00066-3

Lazarus, M., García Ochoa, G., Truong, M., & Brand, G. (2023). Making the invisible visible: How cultural hegemony and uncertainty help us understand health professional education inequities. Focus on Health Professional Education: A Multi-Professional Journal, 24(3), 115–125. https://doi.org/10.11157/fohpe.v24i3.705

Lazarus, M. D., Gouda-Vossos, A., Parasnis, J., Davis, E. A., Mujumdar, S., Ziebell, A., & Brand, G. (2024). The human element: How educators can prepare learners for future workplace uncertainties and troublesome knowledge. In J. P. Davies, E. Gironacci, S. McGowan, A. Nyamapfene, J. Rattray, A. M. Tierney, & A. S. Webb (Eds.), Threshold concepts in the moment (pp. 186–208). Brill. https://doi.org/10.1163/9789004680661_013

Lazarus, M. D., Ochoa, G., Truong, M., & Brand, G. (in press). Advancing social justice teaching in the health professions through interdisciplinary approaches: Uncertainty tolerance teaching practices & cultural literacy pedagogy. In J. Gingras & J. Brady (Eds.), Teaching social justice in health professions education: Pedagogy and praxis. University of Regina Press.

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About the authors

name: Dr. Georgina C. Stephens, MBBS(Hons) PhD FHEA

institution: Monash University

website: https://research.monash.edu/en/persons/georgina-stephens

As a Senior Lecturer in the Centre for Human Anatomy Education at Monash University and medical practitioner by background, Georgina has first hand experience of what it means to manage uncertainty when caring for people seeking healthcare. Dr. Stephens transitioned to a full time academic career in 2017, focussed on clinical anatomy education and health professions education research. During her doctoral studies, she explored how medical students experience uncertainty, and examined the evidence for widely used scales intended to measure the construct of uncertainty tolerance. Her doctoral research led to five peer reviewed publications on uncertainty tolerance, all published in leading health professions education journals, and several winning awards for publication excellence. Georgina is an award winning educator, including being awarded the Dean’s Award for Innovation in Education in 2023.

name: Prof Michelle Lazarus, PhD SFHEA

institution: Monash University

website: https://research.monash.edu/en/persons/michelle-lazarus

As a Professor and Director of the Centre for Human Anatomy Education and the Deputy Director for the Monash Centre for Scholarship in Health Education at Monash University, Michelle has been in the field of medical education for over a decade, leading a research program which explores how to impact learners’ uncertainty tolerance through curriculum design. She has delivered over a dozen related workshops to educators across the globe, and has developed a series of educational artefacts to support learner uncertainty tolerance development, including a pamphlet and webinar, for Education Services Australia for teachers interested in integrating uncertainty tolerance teaching practices in their classrooms. This textbook expands on these initiatives, providing a more holistic and complete source of uncertainty tolerance theory and practice – focusing specifically on health professions educators. Michelle is an award winning educator and author. Notably, she was awarded the Australian Award for University Teaching Excellence in 2021. She is the author of the “The Uncertainty Effect: How to Survive and Thrive through the Unexpected”. Her entire career is a journey into uncertainty.