Chapter 18: Navigating Challenges, Pitfalls, and Tensions in Uncertainty Tolerance Teaching Practices

Case Study 18.1: Selma Just Wants Some Certainty

Case Information

Selma is a third-year medical student. She recently completed the preclinical component of her program and is excited to commence her year-long placement at a rural base hospital. Selma graduated top of her year in high school and has kept a high-distinction average for assessments during the first two years of medical school. Her academic performance in high school earned her a prestigious scholarship, and to retain it she needs to maintain at least a distinction average. To preserve her excellent academic performance, Selma has relied on a strict study regime, including creating and memorising flashcards and reviewing past exam papers. These study strategies have helped her perform academically while managing her attention deficit hyperactivity disorder.

When Selma starts her placement, she finds the learning environment vastly different from anything she encountered during the preclinical phase of her course. In her preclinical years, she had a clear timetable of lectures, tutorials, and workshops each week. Now, although she has been given a curriculum guide and a timetable with some formal small-group tutorials and workshops, there are several days each week devoted to ‘self-directed placement-based learning’. During this self-directed time, Selma finds she is mostly following junior doctors on ward rounds, sitting in on clinics, or observing from a distance in theatre. She isn’t clear what she is meant to be learning or who she should be learning from. It is particularly frustrating to Selma that the year will consist of general medical, general surgical, and orthopaedic rotations, as these are the only units in the base hospital. In comparison, her peers placed at city hospitals are on specialty rotations like cardiology and oncology. Selma notes that her curriculum includes conditions treated by these specialties and feels she is unfairly missing out on getting the facts from experts that she will need to succeed in her exams. Furthermore, the tutorials and workshops are mostly in a flipped classroom format, which Selma understands to mean that students need to come up with answers in class, rather than the answers being provided by educators.

Across the semester, Selma learns from a variety of clinicians and educators. She notes differences in how they approach some aspects of medicine and that often their approaches differ from those laid out in the curriculum documents and prescribed course textbooks. Selma is unsure how to manage these differences and how to find out which is the right way to manage situations. She searches the literature to find out what is best but even here finds different descriptions across the various guidelines and review papers.

By the end of the semester, Selma feels tired, frustrated, and even angry about the uncertainties she has experienced while just trying to do her best to learn enough to do well in her exams. Instead of following the junior doctors around, she now often pretends to have a tutorial and heads to the library to study. When asked by the course convenors to complete an evaluation of teaching and units, Selma indicates she is unsatisfied with the lack of lectures she has had compared to those in the first and second years, the differences between clinical placement sites, and the inclusion of subjective assignments such as critical incident reflections. She also notes that it is unfair that students need to come up with answers during workshops and says that learning would be more effective if it were expert-led to ensure students got the right answers.

Case Discussion

For learners like Selma who have had great success focussing on rote learning factual information, transitioning to learning that involves inherent uncertainties can be quite challenging. The structure of Selma’s early years in medical school enabled her to continue focussing on certainty with success; however, on commencing her clinical years she has begun to experience considerable uncertainties. Research with medical students in their clinical years demonstrates that this population experiences a wide variety of uncertainties which may be transferable to other health professions learners engaging in work-integrated learning (Stephens, Sarkar, et al., 2022a). These include uncertainties related to learning (e.g., how to learn effectively in clinical contexts and how much to learn within the body of knowledge for the profession), professional identity formation (e.g., what caring means for a professional in comparison to caring in one’s personal life), and clinical practice. The uncertainties may be particularly pronounced at transition points. Selma is experiencing one such point, in which what is considered known is challenged through new understandings. This can lead to feelings of discomfort. When uncertainty becomes overwhelming for learners, they may respond by trying to reduce the uncertainty they are experiencing and attempting to return to the certainty of their prior experiences. This response is seen in Selma avoiding engagement with placement-based learning and instead focussing on library-based learning. Theories such as uncertainty identity theory and threshold concepts (Chapter 7) are useful for further understanding the uncertainties learners experience at transitions.

It is likely that Selma’s prior educational experiences, focussed on achieving the high grades required for admission into the medical program, have moderated her experiences of uncertainty (Stephens, Sarkar, et al., 2022b). For educators with learners whose experiences are similar to Selma’s, the challenge is to ensure they are not overwhelmed by uncertainty and are instead able to experience uncertainty through clinical placements with enough support to engage with learning and start developing skills for managing uncertainty. This can be achieved by identifying relevant learner-, educator-, and system-sourced moderators (Chapter 5) that together create support for learners as they begin to understand that much of their future careers will require managing uncertainty.

Key learner-sourced moderators relevant to Selma’s case may include merit-minded learning goals (e.g., focus on achieving high distinctions); neurodivergence, personality, and mental health factors (e.g., attention deficit hyperactivity disorder); and an objective worldview (e.g., seeking the single correct approach among different approaches to patient management observed on placement). To support Selma’s growth beyond a merit-minded focus, educators could ask her to reflect on other ways in which she finds a sense of purpose within medicine (e.g., advocating for person-centred care or social justice issues); this may help provide a reason for learning to manage uncertainty. While neurodivergence may influence learners’ uncertainty tolerance, this moderating factor is very individualised. Accordingly, educators should learn about an individual’s particular learning needs and work with these, including with university learning support services as required.

While it is unclear from the case information what strategies educators have already used to ensure learners in Selma’s cohort are prepared for managing uncertainty, it seems that Selma herself had little guidance regarding how learning approaches evolve across the medical program. This could be addressed by ensuring any orientation to placements includes advice about how to engage with learning on clinical placements, such as learning through interaction with patients as well as following and observing healthcare professionals. Selma may also not understand the career value of managing uncertainty, which could be discussed during orientation and reiterated during tutorials and workshops. Such workshops could include educational uncertainty stimuli such as grey cases that may help illustrate how an objective worldview is unlikely to capture all the complexity, ambiguity and nuance of clinical practice. Orientation could also include formal time for peer support interactions to moderate cohorts’ management of uncertainty in clinical placements. Engaging the support of near-peers can be helpful in these circumstances, as hearing about the need to manage uncertainty from those closer in experience can demonstrate to learners that managing uncertainty is a skill required for ongoing learning and patient care (Stephens, Sarkar, et al., 2022a; Stephens & Lazarus, 2024).

Learner evaluations of teaching and units typically have a considerable impact on the delivery of health professions programs. However, educators should understand that solutions proposed by learners may not always address what they need to advance their learning about uncertainty. In other words, because learners aren’t healthcare professionals, they may not yet know all the methods which are best for their learning. In this case, Selma provides negative feedback about the role of reflective learning and says she would prefer more educator-led lectures (i.e., didactic teaching) instead of student-centred learning supported by experienced guidance. Acquiescing to such requests may hinder students’ development of skills for managing uncertainty and result in graduates entering practice ill-equipped for adaptively managing uncertainty in their careers. Rather, educators should reflect on the themes of learner evaluations to understand what learners are struggling with and should implement evidence-based approaches to better prepare them for managing uncertainty. Together, these approaches may help learners like Selma understand the nature of uncertainty in healthcare and ensure learners remain engaged with learning throughout their programs.

Case Study 18.3: Duncan Needs to Demonstrate That His Course Prepares Learners to Manage Uncertainty

Case Information

Duncan is a musculoskeletal physiotherapist, an associate professor, and the program director for a doctor of physiotherapy degree. The national accreditation council has informed Duncan that the program he directs is due for routine reaccreditation and will be visited by council representatives 12 months from now. Part of the accreditation requirements is that physiotherapy learners be prepared for the ambiguities, complexities, and uncertainties of practice.

Based on many successful reaccreditation efforts he has led previously, Duncan is confident he can demonstrate that his graduates achieve core competencies such as appraising and applying evidence and demonstrating ethical and person-centred care. To achieve this, he has carefully developed the program to ensure core competencies are scaffolded across the duration of the program. However, he is less confident that he can demonstrate that the learners are able to effectively manage the uncertainties of graduate physiotherapy practice. Duncan understands how he manages uncertainty during his own patient encounters but is unsure how the many different staff who teach in the doctor of physiotherapy ensure learners are adequately prepared for this. Duncan is also concerned there is a tension between demonstrating physiotherapy graduates’ competencies in core knowledge and skills and their competency for managing uncertainty, and that introducing learners to uncertainty in the early years of the program could confuse them and undermine the program structure.

Duncan does a little research into the literature on uncertainty tolerance and notes how scales are commonly used in studies of physicians. This gives him the idea to implement a quick learner survey at the start and end of the program, using a previously published uncertainty tolerance scale: it could be an effective and efficient way to demonstrate to the accreditation council that his learners have developed skills for managing uncertainty.

Case Discussion

Skills for managing or tolerating uncertainty are increasingly included in undergraduate and professional training frameworks, including physiotherapy practice, as described in Duncan’s case (World Physiotherapy, 2021). Accordingly, educational leaders may be asked by accrediting bodies to demonstrate that should learners are being prepared for uncertainties to the level required of program graduates. While Duncan is an experienced educational leader who has successfully navigated prior accreditations, the requirement he now faces relating to managing uncertainty is, somewhat ironically, causing him to experience uncertainty. However, Duncan likely has the expertise to successfully lead his team through this component of the reaccreditation. Most importantly, he understands the career value of managing uncertainty as a physiotherapist. As described in Chapter 15, this includes diagnostic uncertainties and an evolving evidence base for active therapies. In addition, his educational approach in general involves scaffolding of learning across the program. If he takes his knowledge of how graduates will need to manage uncertainty and applies his existing scaffolding approach, he should be able to build a strong case for the accreditation council that his learners are well prepared to manage uncertainty. Instead of worrying that learners in the early phase of the program may be confused by exposure to uncertainty, Duncan can be reassured that scaffolding uncertainty can help introduce learners to uncertainty relevant to their learning stage and can build a toolkit for managing uncertainty across their program.

If details are not included in the accreditation framework, Duncan may need to review literature on the different ways physiotherapy graduates will be required to manage uncertainty. This will help ensure his knowledge not only is drawn from his professional experience as a musculoskeletal physiotherapist but also reflects the different career paths his graduates may take. With this information, Duncan can then review the physiotherapy program for opportunities learners have to develop skills relating to uncertainty. Rather than building a curriculum for managing uncertainty from scratch, Duncan should be aware of the likelihood that many educators in the physiotherapy program are already teaching in a way that implicitly supports learners’ skills for managing uncertainty (Lazarus et al., 2024). There are also likely to be teaching and activities to which small adjustments can be made to more effectively incorporate uncertainty. For instance, reflective learning completed during placements could include prompts to describe scenarios in which there was diagnostic uncertainty, and case-based learning could be adjusted to ensure more than one answer is correct based on the available information (i.e., grey cases).

Because the concept of uncertainty tolerance teaching approaches may be unfamiliar to educators, the curriculum-mapping exercise could involve Duncan facilitating staff workshops which raise awareness of the uncertainty tolerance construct and teaching approaches. During these, educators could engage with the reflective prompts included throughout this handbook (see ‘Uncertainty Tolerance Teaching Development Activity’ in the Resources section) to help them identify ways in which they already support learners’ uncertainty management and strategies to improve them. This approach may allow Duncan to build a community of practice and capacity for uncertainty tolerance teaching in the physiotherapy program.

In tandem with the workshops on curricular mapping, Duncan will need to review the program’s assessment strategy and how it can demonstrate to the accreditation council that learners are adequately prepared for the ambiguities, complexities, and uncertainties of practice. This may involve the stages described in Chapter 6, which are founded in principles of authentic and programmatic assessment. As with teaching activities, it is likely that some assessments, especially those that are highly authentic, already integrate uncertainty management or can do so with small adjustments. For instance, an objective structured clinical examination station about diagnosing and managing a sporting injury could incorporate communicating uncertainty about the patient’s recovery duration.

Although Duncan is interested in using uncertainty tolerance scales to gather evidence that his graduates can manage uncertainty, there are substantive limitations in validity evidence supporting the use of such scales with health professions learners (Stephens, Karim, et al., 2022; Stephens et al., 2023). Uncertainty tolerance scales commonly implemented with populations of health professions learners and healthcare professionals have largely been developed with test populations of physicians and, to a lesser extent, medical students, with far less (or absent) validity evidence regarding other health professions learner populations. Therefore, should Duncan decide to implement an uncertainty tolerance scale in his program, he should firstly evaluate the validity evidence for his chosen scale in physiotherapy learners. Furthermore, commonly used scales tend to focus on emotional responses to uncertainty (e.g., anxiety and stress) rather than the actual management of uncertainty (often related to cognition and behaviours) required for reaccreditation. Accordingly, focussing on how his program teaches and assesses uncertainty management is likely to be most effective for reaccreditation and supportive of Duncan’s learners.

Although this case focusses on the need for educational leaders to provide evidence of graduate preparation for practice uncertainties, at present, some accreditation councils may instead privilege and require traditional and objective approaches to assessment that limit capacity to include uncertainty tolerance teaching practices (e.g., approaches that focus on single correct answer multiple-choice questions). Objective approaches are often used to make high-stakes decisions, such as determining whether a learner’s knowledge aligns with national standards and whether they can commence practice. However, the growing evidence base presented in this handbook demonstrates that managing uncertainty should not be separated from core learning, nor does it need to be. Educational leaders should feel empowered to ensure their programs equip health professions learners with the skills needed for graduate practice, even if these are not explicitly required at present by accrediting bodies.