Chapter 11: Foundational Medical Science

Uncertainty in Foundational Medical Science

The scientific evidence that is foundational to medical practice (e.g., physiology, anatomy, biochemistry, pharmacology, and so on) has expanded considerably since the mid-20th century. Although more knowledge is now at the doctor’s fingertips, sources of uncertainty in medical practice remain plentiful and are experienced by doctors across all career stages and specialisations. For experienced doctors with an in-depth understanding of the scientific basis of their practice, uncertainties may arise due to limitations in the body of medical evidence (Han et al., 2011); unpredictability of the future outcome, including as it relates to individual illness progression; and complexity of the patient’s case, such as the presence of multiple diseases (Hillen et al., 2017). Further uncertainties may relate to how to effectively communicate scientific knowledge to patients (Han et al., 2011; Simpkin & Armstrong, 2019).

However, learners entering medical school often conceptualise foundational medical science and uncertainty quite differently from experienced healthcare professionals. A qualitative study of early years medical students identified beliefs among them both that foundational medical science is complete and certain and that it is equally applied to all patients (Knight & Mattick, 2006). Beliefs that knowledge is ‘black and white’ are particularly described in relation to anatomy (Knight & Mattick, 2006; Stephens et al., 2021), with novice learners typically incorrectly perceiving that all anatomy is known and knowable. Uncertainty may arise later in medical school and in early clinical practice due to learners’ knowledge gaps, which may in turn arise from deficits in their learning or in the medical evidence base (Stephens et al., 2022). Additionally, uncertainty for these learners can be present when they apply foundational medical science to real-world contexts, in which knowledge becomes relative to the care of individual patients in particular settings. Many learners can, with experience including uncertainty tolerance learning opportunities, begin to recognise and accept uncertainty in medical knowledge (Stephens et al., 2021).

Priorities in Preparing Learners for Uncertainty in Foundational Medical Science

Commonly, graduating doctors commence clinical practice with support from senior clinicians and later transition to independent practice. Across their formative learning years, doctors are likely to experience multiple transitions in their roles as they build towards this independent practice – for example the transitions from preclinical learning to learning within healthcare settings, from being a medical student to being an intern or postgraduate year 1 doctor, and from being an intern or junior resident to being a senior specialty trainee or fellow with greater responsibility. Medical students need to acquire the core foundational medical sciences knowledge alongside clinical skills reliant on the application of this knowledge to begin safely caring for patients. A challenge in this trajectory is balancing the foundational science ‘knowns’ with the uncertainties of applying that knowledge to healthcare practice and individualised patient care.

Fostering Uncertainty Tolerance in Foundational Medical Science Learners

Learners in medical programs need to gain awareness of the presence of uncertainty in clinical practices and to recognise the different ways in which uncertainty may arise in such contexts. Furthermore, learners benefit from practising adaptive management of uncertainty in lower-stakes learning environments, such as the classroom or laboratory; from here, skills and attributes gained may be transferred to settings in which the stakes are higher, such as work-integrated learning contexts. A scaffolded approach to introducing healthcare-related uncertainty and adaptive responses to it can help ensure that learners are able to apply foundational science knowledge in a manner relevant to their future careers.

Exemplar Activity: Uncertainty in Case-Based Learning

Activity Origin

Through longitudinal qualitative research, the authors identified that medical students associated anatomy knowledge with certainty in patient care (Stephens et al., 2021). Learners perceived that if they gained enough anatomical knowledge or ordered further investigations, they would be able to achieve a definitive diagnosis. However, in real-world medical practice, there are gaps in anatomical knowledge, individual variations in topographical structure, and instances of diagnostic uncertainty.

To address learners’ misconception that anatomy knowledge leads to clinical certainty (Lazarus et al., 2018), we adapted case-based learning (CBL) to incorporate purposeful uncertainty. Often, CBL has a clearly defined end point – for example, learners uncover a definitive diagnosis or single best approach to management. In contrast, the activity below contains features of CBL approaches (e.g., a clinical case description that progressively reveals more information) but has ‘fuzzy’ end points, including several options that are appropriate based on the information provided and that can be narrowed down to a list, as opposed to a definitive, clear-cut answer. To balance certainty with uncertainty, the activity ends with a description of core anatomical concepts that learners need to apply to manage the uncertainty in the case, thereby preparing them for engagement of foundational medical science more reflective of clinical applications.

Sources of Uncertainty

The goal of these grey cases, or uncertain CBLs (U-CBLs), is to simulate sources of uncertainty experienced by practising doctors while teaching foundational anatomy science content. To accomplish this, they are purposefully brief and balance the provision of information with aspects of clinical uncertainty. Information provided typically relates to the patient (e.g., reason for seeking care, responses to questions asked by the doctors about their presenting complaint or medical history), examination findings, and investigations (e.g., laboratory and imaging studies, the findings of these). U-CBLs introduce uncertainty through the following sources:

• limitations in the body of medical knowledge (e.g., lack of research into a specific condition, conflicting findings across studies, gaps in research for particular population groups)
• interpretations of clinical examination and/or investigation findings (e.g., false-negative or -positive test results, context influencing investigation interpretations)
• complexities of case presentation (e.g., mix of acute and chronic symptoms, ‘subtle’ symptoms, equivocal or absence of ‘typical’ or ‘textbook’ examination findings)
• identifications of the next best steps (e.g., tensions between ongoing investigations, watchful waiting, definitive diagnosis).

Facilitator Guide

The U-CBL described in this activity is based on a presentation to the emergency department (ED) for acute onset abdominal pain. Learners work together to identify the relevant case information and discuss the presented options, relying on their knowledge of anatomical structure and relations (moderator: high subject proficiency). To regulate the extent of uncertainty within the anatomical region and to ensure that multiple cases can be covered in a single workshop, potential options are narrowed by the educator to a defined list similar to an extended matching question (moderator: scaffolding uncertainty). The learning objectives for the U-CBLs are as follows:

• practise clinical reasoning skills
• identify complexities related to clinical diagnosis and treatment
• distinguish areas of the healthcare environment which rely on knowledge of anatomical structure, relations, and concepts
• develop professional identity as a future healthcare worker as this relates to professional role, teamwork, and managing uncertainty connected to patient care.

Indications of how well learning objectives have been met include:

• how learners describe their choices (e.g., explaining why they included or excluded options)
• learners’ identification of multiple options as possible and plausible based on the available information
• learners’ reflections on how this approach may impact them in their career.

In the authors’ context, before learners participate in their first anatomy U-CBLs, learners are introduced to the importance of learning to manage uncertainty for their future careers using a real-world case (moderator: career value). For instance, career value may be approached through a story explaining the role of a doctor in managing the uncertainty related to the COVID-19 pandemic using information that learners have some familiarity with. The discomfort that typically accompanies experiences of uncertainty is continually discussed and normalised (moderator: setting clear expectations), to help learners process and progress through this discomfort and understand that uncertainty is experienced even by those with greater expertise and experience. Psychological safety (moderator) is critically important, as risk and fear of retribution for incorrect answers or for speaking up can decrease learners’ uncertainty tolerance. In support of this, U-CBL sessions should be formative, and educators should encourage, reinforce, and model diverse answers to posed queries (moderators: intellectual candour, pastoral care).

Key considerations for educators before implementation of U-CBLs include the following items, many of which relate to the moderators described in Chapter 5:

• understanding learners’ previous experience with managing uncertainty broadly in education and more specifically in clinical cases (moderator: scaffolding uncertainty)
• introducing learners to the purpose of and motivation for managing uncertainty (and related discomfort) (moderator: career value)
• building on prior learning (e.g., anatomical conceptual/theoretical knowledge from lectures, anatomical structure names and relationships from laboratory or practical classes) (moderator: high subject proficiency)
• setting clear expectations (moderator), including the requirement for learners to discuss the case within their small groups (moderator: diverse teamwork) and to volunteer perspectives they can share with the larger group (moderator: responsible for knowledge).

Regarding pastoral care (moderator), educators should consider:

• using an open and inviting communication style
• seeking diversity when selecting discussion participants (ensuring different students or groups of students are contributing to the discussion at each opportunity)
• avoiding negative comments about contributions (e.g., ‘That’s incorrect’, ‘That’s not the right answer’).

In implementing U-CBL activities, educators also need to think about infrastructure, including:

• teaching spaces (flat floor or stadium-type seating is ideal)
• resources (paper, whiteboards and markers, computers)
• staffing (number of staff, expertise, and training).

In the authors’ context, each session lasts 90–120 minutes, and learners progress through three or four cases per session. There are 320 learners in a large, flat floor space; learners sit in groups of six around tables, each of which has a whiteboard top. In the absence of whiteboards, butcher paper or other low-fi writing resources would also work well. Staffing comprises the lead clinical anatomy academic and four to eight medically qualified or clinical anatomy teaching assistants, depending on availability and student number.

Learners can elect whom they sit with and are encouraged to use both the whiteboards and their computers as they work as a team through the U-CBL. The cases are designed so that the learners are pushed a little bit outside their expected foundational science knowledge, and computers become effective tools for accessing research material to address this gap. To enhance learner inclusivity, cases are displayed on a screen and where applicable are printed out for reference, as questions are posted sequentially on slides.

Following provision of case information and posing of a question, a timer is set for three to five minutes. Time is added depending on how learners are progressing. Learners discuss each case-related question before moving to the final case review, during which the key anatomical and clinical knowledge underpinning the case is discussed, the relevant anatomical structures and relationships to the case are reinforced, and these are linked back to the uncertain elements of the case (e.g., differential diagnosis).

The case that follows describes a 32-year-old with abdominal pain. Uncertainty arises in this case regarding the following factors:

• the cause of the abdominal pain
• the cause of the vaginal bleeding
• the cause of the shoulder pain
• the sex and gender of the patient (e.g., demographics)
• how the patient’s symptoms relate to the underlying cause(s)
• potentially conflicting symptoms (shoulder, abdominal, and vaginal symptoms).

The key relevant anatomy reviewed in this case includes:

• the relationship between innervation of diaphragmatic peritoneum and referred pain to the shoulder (via the phrenic nerve)
• sites of intraperitoneal fluid collection depending on the position of the person
• patterns of pain for abdominal and pelvic viscera.

Activity

This activity is based on the case presented below, and will go through the case-related questions in turn, representing how the case is delivered in the learning setting.

 

The first question eases learners into the ideas that there is more than one relevant answer when considering individualised medical care and that investigation ordering can be complex, must be justified, and should be prioritised based on the case. Working in small groups (moderator: diverse teamwork), learners can draw upon each other’s prior experiences (moderator: high subject mastery), knowledge, and different approaches to begin narrowing down their next best step, including laboratory investigations (blood count, liver and pancreas enzymes, pregnancy test) and imaging options. Discussions typically centre on the nature of the pain (e.g., referred versus direct), the location of the pain (abdomen versus shoulder), and identifying which investigations could help learners develop their differentials.

When the whole group comes together to discuss this question(moderator: peer learning/teamwork), the facilitator guides the learners towards exploring why particular tests are more important to undertake now rather than later (moderator: expert guidance). All options could be justified, but some are more relevant than others, based on the presented case information. Accordion 11.1 contains facilitator notes for each option, including discussion points with particular relevance to the Australian healthcare system. Click on each option to learn more.

 

Following the discussion, instead of offering up the outcomes of the investigations, the facilitator asks the learners to narrow down their differentials based simply on the justifications they provided for the investigation ordering. At this stage, the learners’ uncertainty should be reduced due to the discussion. At this point in the U-CBL, the educator should ensure that the learners’ discussion has led to the conclusion that the pain is most likely due to referred pain and that Alex is a cis-gendered female. The facilitator introduces the concept of Occam’s razor, which posits that in many circumstances, instead of each symptom having a different cause, there is a single cause that explains many (if not all) of the symptoms. An element of the case that remains unexplored at this stage, and may therefore influence learners’ to defer to Occam’s razor, is Alex’s reported vaginal bleeding, about which only its presence is known. Learners don’t yet know whether it is due to Alex’s typical menstrual bleeding (expected timing and amount) or is unexpected bleeding for some other reason.

 

In Question 2, learners progress through the uncertainties of the case by drawing upon prior anatomical knowledge and the previous discussion to narrow down a list of potential differentials (moderator: high subject mastery). Importantly, the final list of differentials can further stimulate learners’ experiences of uncertainty by challenging their preconceptions – for example, regarding vaginal bleeding (e.g., all women with vaginal bleeding and abdominal pain are suffering from ectopic pregnancies), as the nature of Alex’s vaginal bleeding is purposely not reported in this case via the educator in order to retain a degree of uncertainty in the potential differential diagnosis.

Accordion 11.2 contains the facilitator guide for Question 2. The information presented in it can be used by educators to guide learner discussion. Click on each option for more information.

 

All of the presented options may explain Alex’s case; however, some are more relevant than others, based on linking information provided and in the context of Occam’s razor. The top differentials are ruptured appendicitis, ruptured ectopic pregnancy, and splenic artery aneurysm rupture, as each can explain the non-specific abdominal pain and the referred pain to the shoulder with repositioning.

This case may provide the opportunity to highlight the value of history-taking in developing a list of differential diagnoses (e.g., in Alex’s case, finding out more about the nature of the vaginal bleeding and the abdominal pain). Extending the case to incorporate skills for history-taking, learners could also explore how to ask about Alex’s gender identity, menses, and pregnancy status.

Further sources of uncertainty in this activity are related to the scheduling of the case with regard to the larger medical curriculum. In some years, this case is delivered in the abdominal anatomy block, prior to the pelvic anatomy block. In this context, a source of uncertainty can be the limits of learners’ pelvic anatomy knowledge. Learners can respond to this uncertainty through information-seeking, using their computers to research topics further. Educators need to be aware of the tension between information-seeking as an adaptive response to uncertainty (e.g., identifying the depth of research into ectopic pregnancy, such as associated pain) and information-seeking as a maladaptive response (e.g., collecting as much information as possible, even if it isn’t related to the case, such as population frequency of ectopic pregnancies, all the locations of potential ectopic pregnancies, or all ectopic pregnancies’ associated symptoms) (Stephens et al., 2021). (For more about adaptive and maladaptive responses to uncertainty, please refer to Chapter 3.)

Closing

While this case concludes with some uncertainties, the activity closes with a review of relevant anatomy to illustrate how knowledge (i.e., certainty) can be used to address and adaptively respond to clinical uncertainty, and learners leave the case with an understanding of why some of the options are possible and the relevant anatomical knowledge underpinning these options. This situation mirrors what learners may ultimately encounter in practice – for example, when ending a shift or a clinical rotation when a patient’s case continues beyond their professional involvement.

Impact

Earlier iterations of this activity were formally evaluated as part of a longitudinal qualitative study (Stephens et al., 2021) in which the activity’s influence on learners’ uncertainty tolerance development was recognised. Initially, learners attempted to achieve ‘certainty, for instance, by ‘ordering all the tests’ listed in Question 1. Over time and with increased experiences of learning with U-CBL the study identified evidence of learners’ acceptance of uncertainty tolerance as a clinical competency.

All versions of this activity have been evaluated experientially, through observations by the teaching team, for continued quality improvement. The observations suggested that while some learners enthusiastically embrace these types of U-CBLs, some need more support to engage with them. Support can include verbal reassurance from the educator that it is common to experience the discomfort of not knowing the ‘answer’, reminders that these types of uncertain cases will be relevant for learners’ futures (moderator: career value), and examples of how the expert facilitator would work through one of the choices, providing a working model for learners before they break into working groups (moderator: expert guidance). The more learners practise within this psychologically safe environment (moderator), the more adaptable they are likely to be when facing similar challenges in their clinical futures. Based on the authors experiences, weaving these types of activities throughout a unit, a year, or a curriculum increases the chances that more learners will move from maladaptive to adaptive responses to educational uncertainty.

Adaptations and Summary

As reflective practice seems to be a powerful moderator of learners’ uncertainty tolerance, this activity includes a reflective learning exercise. Following the case completion, the educator asks learners to respond to the following questions (example responses are given below):

1. Which aspects of the case do you feel confident in?
2. Which aspects of the case do you feel unsure about?
3. What steps can you take to consolidate your learning?

For learners who have engaged in reflection on multiple cases, more challenging reflective prompts could be engaged – for instance, how aspects of the case challenged any preconceptions they had about the content presented or how they might change their approach to future cases based on what they learned through the activity. Across a whole curriculum, educators may, at intervals, encourage learners to consider to what extent their reflections have changed, helping them to identify and to become aware of the knowledge and skills they have developed (moderator: capacity for reflection). Educators may then highlight for learners how these can be drawn on during their future healthcare practice.

The questions in this case are skewed towards reinforcing foundational science knowledge. For a more holistic case progression that incorporates principles of person-centred care, the first question posed to learners after reviewing Alex’s case may be changed to, What questions would you prioritise asking this patient?’. Extending this case to incorporate skills for history taking, learners could also explore how to ask about Alex’s gender identity, menses and pregnancy status.

While this example uses a case with sequential elements, it can be adapted to a ‘choose your own adventure’ learning activity (Guilding, 2016). For this, an additional element of uncertainty is added, in relation to the order in which learners receive pieces of information as the case progresses. In this approach, the case is presented, the learners write down what they think is relevant, and then they vote on what they want to see or do next – for example, Alex’s response to history questions, physical examination findings, laboratory test results, imaging findings, and so on. Audience-response technology, such as Poll Everywhere, is ideal for this step. The learner majority’s preferred next piece of information about the case is provided. For each new piece of information, working as a team, learners write progress notes for the case, including what they believe are relevant aspects in the information, and then they report what they think are the top differential diagnoses, based on what they have noted as relevant. Typically, the differential diagnoses change as the case progresses.

Conclusion

Medical learners need to develop foundational science knowledge that can be applied within uncertain healthcare contexts. Rather than simply educating learners about anatomical ‘facts’, the U-CBL approach provides opportunities for learners to practise managing uncertainty in a supported way within a lower-stakes setting while also teaching key anatomical concepts.

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References

Guilding, C. (2016). Choose your own story: Combining interactive voting technology and high-fidelity patient simulations in the lecture theatre, for large group preclinical medical education. BMJ Simulation & Technology Enhanced Learning, 2(2), 47–48. https://doi.org/10.1136/bmjstel-2016-000106

Han, P. K., Klein, W. M.,  & Arora, N. K. (2011). Varieties of uncertainty in health care: A conceptual taxonomy. Medical Decision Making, 31(6), 828–838. https://doi.org/10.1177/0272989×11393976

Hillen, M. A., Gutheil, C. M., Strout, T. D., Smets, E. M., & Han, P. K. (2017). Tolerance of uncertainty: Conceptual analysis, integrative model, and implications for healthcare. Social Science & Medicine, 180, 62–75. https://doi.org/10.1016/j.socscimed.2017.03.024

Knight, L. V., & Mattick, K. (2006). ‘When I first came here, I thought medicine was black and white’: Making sense of medical students’ ways of knowing. Social Science & Medicine, 63(4), 1084-1096. https://doi.org/10.1016/j.socscimed.2006.01.017

Lazarus, M., Paynter, S., Stephens, G., & Rees, C. (2018). Who am I? Investigating the impact of anatomy education on healthcare students’ professional identity [Meeting abstract]. The FASEB Journal, 32(S1), 95.2. https://doi.org/10.1096/fasebj.2018.32.1_supplement.95.2

Simpkin, A. L., & Armstrong, K. A. (2019). Communicating uncertainty: A narrative review and framework for future research. Journal of General Internal Medicine, 34(11), 2586–2591. https://doi.org/10.1007/s11606-019-04860-8

Stephens, G. C., Rees, C. E., & Lazarus, M. D. (2021). Exploring the impact of education on preclinical medical students’ tolerance of uncertainty: A qualitative longitudinal study. Advances in Health Sciences Education, 26(1), 53–77. https://doi.org/10.1007/s10459-020-09971-0

Stephens, G. C., Sarkar, M., & Lazarus, M. D. (2022). ‘A whole lot of uncertainty’: A qualitative study exploring clinical medical students’ experiences of uncertainty stimuli. Medical Education, 56(7), 736–746. https://doi.org/10.1111/medu.14743