Chapter 4: Purposefully Stimulating Uncertainty in Health Professions Education

Health professions learners experience ‘a whole lot of uncertainty’ (Stephens et al., 2022). The findings of research with medical students suggests that uncertainties may relate to learning (e.g., what to learn and how to learn effectively), career (e.g., developing a professional identity), and clinical practice (e.g., complexity, probability, and ambiguity related to caring for patients discussed in Chapter 1) (Stephens et al., 2021; Stephens et al., 2022). Although some uncertainty stimuli are within the control of educators, some are not – for example, the complexities of placement-based or work-integrated learning can stimulate many uncertainties for learners.

With this in mind, this chapter discusses some educational uncertainty stimuli identified across the literature (Lazarus et al., 2023; Patel et al., 2022; Stephens et al., 2022), and begins to explore how these may be purposefully integrated within educational activities to allow learners to practise managing uncertainty when the stakes are (relatively) low. Critically, stimulating uncertainty should not be conceptualised as the opposite of building knowledge. Rather, uncertainty stimuli provide opportunities for educators to guide learners in constructing and applying discipline knowledge in a manner reflective of the real world with its inherent uncertainties.

Educational Uncertainty Stimuli

The authors have identified four educational uncertainty stimuli, or practical ways in which health professions educators can purposefully stimulate uncertainty, which are referred to here as questioning preconceptions, transferring learning, representing multifaceted perspectives, and engaging grey cases  (Lazarus et al., 2023; Stephens et al., 2021). Each of these educational uncertainty stimuli serves to destabilise learners by challenging their perspectives and positions, forecasting uncertainty in their future careers, or placing them in unfamiliar situations and environments. This list is not exhaustive; rather, the educational uncertainty stimuli described here serve as a starting point for ideas about different approaches which educators can use to stimulate uncertainty in health professions education. Chapter 7 delves further into educational theory relevant to developing learners’ uncertainty tolerance through learning activities.

Questioning Preconceptions

Educators can stimulate uncertainty in their learners by pushing them to question their tacit knowledge, belief systems, and perceived truths (Figure 4.1). Questioning preconceptions can be led by educators (e.g., using Socratic methods) or by peers when educational activities are developed in a manner that generates debate among learners. By learners sharing and valuing different perspectives, and being given opportunities to reflect on the perspectives of themselves and their peers (see Chapter 5), they are confronted with the idea that knowledge and concepts may not be as clear-cut as they initially seem.

For example, a conceptual challenge in which learners are required to debate the role of healthcare might, along with developing understanding of evidence-based healthcare, raise the suggestion that the purpose and value of healthcare means different things to different learners, thereby introducing uncertainties related to the topic. For instance, some learners may consider healthcare’s purpose to be focused on extending life, while others might consider the role of healthcare as centred on improving quality of life, while others might consider both a primary – though not always possible in all situations.

Transferring Learning

Activities which challenge learners to apply knowledge learned in one context to another context, termed transferring learning, can stimulate uncertainty (Figure 4.2). Transferring learning draws on the concept of  transfer from the education literature (Carraher & Schliemann, 2002; Dohn et al., 2020), which describes the challenges learners face when applying knowledge and skills learned in one context to another. Learners typically experience uncertainty about which aspects of prior learnings apply and about what new knowledge may also be required to navigate the novel context.

For example, medical students are often taught history and clinical examination skills related to a particular system (e.g., gastrointestinal; neurological etc.) that are typically structured in a step-wise manner. However, when these learners move to learning within the context of clinical placements they will likely observe clinicians who approach history and clinical examination in slightly different and varied ways depending on a number of factors, such as the reasons for and context of an individual’s healthcare visit, and the clinician’s experiences and preferences. In this way, the pre-clinical knowledge transfer to clinical settings introduces uncertainty.

Multifaceted Perspectives

Multifaceted perspectives can be presented through panel discussions with representatives from different groups who have an interest in the topic (Figure 4.3). When observing these panel discussions, learners can gain awareness that conflicting perspectives on priorities and values, and ambiguities in best treatment practices can coexist regarding single issues. Such discussions allow learners to build knowledge about given topics while also experiencing uncertainty.

For example, occupational therapists learning about working with people presenting with neck pain could observe a discussion between different healthcare professionals and people with lived experience of neck pain (including those who have sought differing treatments in managing the pain). The healthcare professionals might include an occupational therapist who talks about maintaining activities for people with neck pain; a neurosurgeon who talks about the potential risks, benefits, and unknowns related to surgery and recovery; a radiologist who discusses subjectivity in interpreting medical imaging; a pain researcher who describes gaps in knowledge about the mechanism of analgesic action; and a psychologist who talks about the benefits of cognitive behavioural therapy for managing physical symptoms. Multifaceted perspectives may even arise within monodisciplinary panel discussions – for example, a group of surgeons talking about their individualised techniques for managing a given pathology. In this way, uncertainty is stimulated for learners as they observe how the same topic has varied perspectives, and ambiguous knowledge.

Grey Cases

Educators can stimulate uncertainty for learners by using grey cases (Figure 4.4), which are case-based learning activities that include multiple forms of uncertainty (Lazarus et al., 2023; Stephens et al., 2021). Uncertainties within grey cases are designed to authentically represent how real-world uncertainty may arise in healthcare settings and to avoid the typecast, single-end-point approaches of some case-based learning. The key to turning traditional case-based learning into an uncertainty stimulus is to ensure that, as with real-world healthcare, not everything about the case is known and the future remains uncertain. Grey cases may be delivered across a variety of settings, including classroom-based activities, simulation, and online learning.

Uncertainty may be built into a case by limiting or omitting information provided to learners through the case scenario, providing case details that seem to conflict, or by incorporating ambiguous endpoints (e.g., allowing multiple valid answers or interpretations based on what is known about the case). Alternatively, an educator could introduce variable case progression or parameters that change when a case has been solved, asking learners how their answers would change with different preferences or demographics, or simulating changes in vital signs from those initially presented.

Uncertainty Stimuli and Curricula Design

When designing curricula intended to support health professions learners to develop skills for effectively managing uncertainty, it is important to consider where and how uncertainty stimuli arise in the learning journey, including both within and external to educator control. Uncertainty stimuli, by their very nature, can create a sense of unmooring for learners, which can often generate feelings of unease and discomfort. Depending on the individual learner and their prior experiences (alongside other moderating factors), ill-conceived or ill-timed uncertainty stimuli could create experiences that cause learners to fear and try to avoid uncertainty rather than accepting and managing it. Conversely, well-considered uncertainty stimuli that effectively support learners to develop skills for managing uncertainty can help them to accept that uncertainty is part of health professional practice and to navigate the unknown with curiosity and purpose despite the discomfort that uncertainty can provoke. Chapter 6 will describe moderators or classroom approaches which can help regulate the impacts of the educational uncertainty on learners.

Summary

Uncertainty is an inherent part of learning to become a health professional. Consideration should be given to how uncertainty can be thoughtfully stimulated in educational activities and when it is best to do this during learners’ experiences. This approach allows an educator the opportunity to plan a program that progressively increases the challenge and the educational stakes (e.g., vulnerability in the learning community, grades etc.) when managing uncertainty across a learning program. Such educational approaches may improve health professions learners’ capacity for managing uncertainty when they commence practice.

References

Carraher, D., & Schliemann, A. (2002). The transfer dilemma. Journal of the Learning Sciences, 11(1), 1-24. https://doi.org/10.1207/S15327809JLS1101_1

Dohn, N. B., Markauskaite, L. & Hachmann, R. (2020). Enhancing knowledge transfer. In M. J. Bishop, E. Boling, J. Elen, & V. Svihla (Eds.), Handbook of research in educational communications and technology (5th ed., pp. 73–96). Springer Nature. https://doi.org/10.1007/978-3-030-36119-8_5

Lazarus, M. D., Gouda-Vossos, A., Ziebell, A., Parasnis, J., Mujumdar, S., & Brand, G. (2023). Mapping educational uncertainty stimuli to support health professions curriculum development [Manuscript submitted for publication]. Anatomy and Developmental Biology, Monash University.

Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56(12), 1163–1173. https://doi.org/10.1111/medu.14873

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