Is it good to express uncertainty to a patient? Correlates and consequences for medical students in a standardized patient visit
Introduction
The only certainty in medicine is the pervasiveness of uncertainty. Uncertainty can come from the limits of scientific evidence or from an individual's lack of knowledge [1], [2] and patients may not be able to determine the type of uncertainty being conveyed. Many things may communicate uncertainty to a patient, including acknowledging gaps in research, admitting one's own inadequate knowledge, or deferring to other sources.
The communication of uncertainty by health care providers has been defined in various ways [3], [4]. For purposes of this paper, which is concerned with how expressions of uncertainty are perceived, we define an expression of uncertainty (EOU) as any statement made by a provider that either directly or indirectly indicates uncertainty to a patient.
A provider has the option to express uncertainty or not. Even when the visit involves complex medical decisions with unknown outcomes, uncertainty is often not discussed [5]. Although physicians may acknowledge uncertainty in their patients and colleagues, physicians often see uncertainty in themselves as a threat to the authority and infallibility which guides their professional image and their relationship with patients [6].
Teaching medical students about managing uncertainty is a challenging task [7]. Students are especially fearful of looking uncertain and so may fail to express uncertainty at all [8]. Often the education they get about dealing with uncertainty is through watching their instructors and they are mainly taught different strategies for disregarding uncertainty [2]. They often ignore the important role of uncertainty and believe that the ‘right’ answer is attainable from some authority on the matter [9].
Medical students may overestimate the negative impact of uncertainty. Schor et al. asked students to estimate the amount of stress physicians experienced due to medical uncertainty and compared it to the physicians’ self-reports [10]. They found that students’ estimation of physicians’ stress was significantly higher than physician self-reported tolerance of uncertainty.
Although there is reluctance in medical students and even practicing doctors to acknowledge uncertainty to themselves and to their patients, experts theorize that the expression of uncertainty in the medical encounter has positive outcomes for both the doctor and the patient. Katz advocated that awareness and disclosure are the best way for physicians to cope with uncertainty [2]. Hewson et al. argued that effectively managing uncertain and complex medical situations is a crucial element of clinical competence [11] and that these issues should be addressed explicitly.
Disclosing uncertainty has also been theorized to reduce the power differential between doctor and patient [2] and to ensure adequate shared decision making [5], [12]. The relationship-centered model of care, in which both doctor and patient bring strengths and limitations to the interaction, implicitly assumes that doctors, as human beings, are not infallible [13], [14].
Although theorists seem relatively united in their assumption that increased acknowledgement of uncertainty is positive for the doctor–patient relationship [3], [5], [15], empirical research on this topic has had mixed results. In some studies, patients prefer disclosure of uncertainty and are not less satisfied with the physician when he/she admits uncertainty [16], asks another physician for advice, or looks in a reference book [17]. In fact, patients may even be more satisfied with more expressions of uncertainty [18]. One group of British patients, who had interacted with medical students during clinical examinations, noted that although confidence was a sign of good performance, they appreciated some degree of humility [19]. Students with an awareness of their limits in knowledge, who still showed confidence, were considered most competent.
On the other hand, a comparison of general practitioners’ and their patients’ ratings of uncertainty statements found that patients were far more likely to rate these as signs of not being confident than doctors thought they would [17]. Johnson et al. experimentally manipulated how physicians expressed (or did not express) uncertainty in videotaped interactions and found that patients were least satisfied with physician who expressed uncertainty [20].
The reasons for these differences in empirical research are unclear. One potential explanation, which has been largely neglected in the literature, is the gender of the healthcare provider expressing uncertainty. Most studies do not explicitly discuss gender [16], [17], [20], or do not look at the correlates and perceptions of EOU use separately by gender [18]. Theorists have not considered that the acknowledgement of uncertainty might be associated with patient perceptions differently for male and female providers.
However, provider gender may impact patient perceptions of EOUs. The existence of gender differences in the behaviors of healthcare providers has been illustrated in the literature [21], [22]. The same behaviors can have different consequences when carried out by a male or a female provider [23], [24], [25], [26] and some of these differences may be explained by gender role expectancies [27].
The present article explores the use of expressions of uncertainty (EOUs) in a sample of medical students during four different standardized patient clinical interactions. The analyses focus on the verbal correlates EOU use, analogue patient and trained raters’ perceptions of students when using EOUs, and the role of medical student gender in both EOU use and its correlates.
Section snippets
Medical student sample
One hundred and forty-seven third-year medical students at Indiana University School of Medicine were videotaped during their objective structured clinical examination (OSCE). Multiple standardized patients (SPs), both male and female, portrayed one of four medical scenarios: (1) discussion of the SP's father's illness and implementation of Do Not Resuscitate (DNR) code status, (2) stress headache diagnosis, (3) cough diagnosis, and (4) smoking cessation counseling. Students participated in
Medical student and interaction characteristics
Descriptive statistics on the sample are given in Table 2. The subsample of 72 medical students viewed by the APs did not vary in composition from the entire sample.
Overall EOU use
Overall there were 179 expressions of uncertainty used by the 147 medical students. The majority of these statements were admissions of a lack of knowledge (55%, see Table 3). Eighty-two (56%) of the medical students did not use any EOUs. The number of EOUs per visit ranged from 0 to 17 with a mean of 1.21 statements per visit (SD =
Discussion
In this study of medical students interacting with standardized patients during their third-year OSCEs, 44% of the students used at least one expression of uncertainty during their 10–15 min encounter. The majority of these statements were admitting a lack of knowledge. While EOUs accounted for a relatively small portion of all statements made by medical students in these interactions, their use had many correlates with verbal behaviors and observer perceptions.
A higher EOU rate was associated
Role of funding
This work was supported in part by a grant to the Relationship Centered Research Network from the Fetzer Institute, Kalamazoo, MI. The funding source had no involvement in data collection, analysis, or the preparation of this manuscript.
Conflict of interest
There are no conflicts of interest.
Acknowledgements
The authors wish to thank Kaitlin Perelly and the research assistants who assisted in this project.
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