Twelve tips for thriving in the face of clinical uncertainty.

Background: Effectively managing clinical uncertainty is increasingly recognized as a goal of medical education. Stress from uncertainty has been associated with depression and burnout in trainees and may also impact patient care. Despite its importance, however, strategies to embrace uncertainty in clinical practice are lacking.Aims: The literature on uncertainty in medicine was reviewed. Incorporating insights from faculty and students, 12 tips for healthcare educators to help themselves and others thrive in the face of clinical uncertainty were developed.Results: Educators will find the tips practical and easy to implement in their day-to-day interactions as clinicians and teachers. Tips are divided into tips for oneself; for implementing with students and trainees; and for implementing with patients and in healthcare systems.Conclusions: These tips can enhance healthcare professionals' and students' ability to thrive in the face of uncertainty. Strategies to embrace uncertainty are critical for ourselves, our trainees, our patients, and our healthcare systems.

Communicating Uncertainty: a Narrative Review and Framework for Future Research.

Discussing the uncertainty associated with a clinical decision is thought to be a critical element of shared decision-making. Yet, empirical evidence suggests that clinicians rarely communicate clinical uncertainty to patients, and indeed the culture within healthcare environments is often to equate uncertainty with ignorance or failure. Understanding the rationale for discussion of uncertainty along with the current evidence about approaches to communicating and managing uncertainty can advance shared decision-making as well as highlight gaps in evidence. With an increasing focus on personalized healthcare, and advances in genomics and new disease biomarkers, a more sophisticated understanding of how to communicate the limitations and errors that come from applying population-based, epidemiologic findings to predict individuals' futures is going to be essential. This article provides a narrative review of studies relating to the communication of uncertainty, highlighting current strategies together with challenges and barriers, and outlining a framework for future research.

Identifying central tenets needed in our education systems: Results from a pilot integrated clinical apprenticeship.

Purpose: The ability of healthcare systems to deliver world-class compassionate care depends on the quality of training and education of staff. Matching student-centered learning with patient-centered care is the focus for much curricula reform. This study explores the effect a novel longitudinal curriculum had on medical students' attitudes and experiences to better identify central tenets needed in our education system. Methods: Single-center, qualitative focus-group study conducted in 2017 of medical students in a longitudinally integrated clinical apprenticeship at a large UK medical school. Students were randomly assigned to focus groups to describe their educational journey and explore how longitudinal learning prepared them for a medical career, valuing their unique position as student participants in the healthcare system. Results: Four themes emerged from students' experiences: navigating the patient journey, their professional development, their learning journey, and the healthcare system. Conclusions: Listening to student voices lends insights for educators refining educational models to produce doctors of tomorrow. This project identified the educational value of students having authentic roles in helping patients navigate the healthcare system and the benefits of consistent mentorship and greater autonomy. The gulf between gaining skills as a future doctor and gaining skills to pass summative exams calls into question assessment methods.

Reconciling technology and humanistic care: Lessons from the next generation of physicians.

PURPOSE: There is concern among physicians that the rising use of technology in medicine may have a negative impact on compassionate patient-centered care. This study explores medical student attitudes and ideas about technology in medicine in order to consider ways to achieve symbiosis between technology use and the delivery of humanistic, patient-centered care. METHODS: This qualitative study uses data from 138 essays written by medical students in the United States and Canada responding to the prompt "Using a real life experience, describe how technology played a role, either negatively or positively, in the delivery of humanistic patient care." Data were analyzed for themes about technology and the impact on humanistic patient care. RESULTS: Seven themes emerged from the medical students' essays: Patient Perspective; Life-Giving versus Life-Prolonging; Boundaries between Human and Technology; Distancing versus Presence; Adapting to Change; Tools to Enhance Care; and Definitions of Technology. CONCLUSION: Listening to medical students lends insight into ways to integrate technology into the healthcare environment, to ensure that physicians' ability to deliver compassionate care is enhanced, not hindered. Utilizing perceptions of the next generation of physicians, educational and developmental strategies are proposed to ensure the successful integration of technology with humanistic patient-centered care.

An Interprofessional Group Intervention to Promote Faculty Well-Being: A Randomized Clinical Trial.

INTRODUCTION: To evaluate the effect on engagement, relational connection, and burnout of an intervention involving clinical faculty meeting in interprofessional self-facilitated groups and to determine whether a written discussion guide is necessary to achieve benefit. METHODS: This is a randomized controlled trial, conducted at a large US academic medical center from May to August 2018. Subjects included 25 clinical physicians, nurse practitioners, and certified nurse midwives. The intervention involved three monthly self-facilitated groups for faculty. Groups were randomized to have no discussion guide, or to receive a one-page guide. Outcomes of burnout, engagement, and empowerment in work, and stress from uncertainty were assessed using validated metrics. RESULTS: Rates of emotional exhaustion and depersonalization decreased significantly over the course of the 3-month study (56%-36%; P < .001; and 20%-15%; P = .006) and overall burnout decreased from 56% to 41% of faculty (P = .002). The percentage of faculty who felt engaged in their work increased from 80% to 96% (P = .03). No statistically significant differences in empowerment at work or in reaction to uncertainty were seen. The groups without a discussion guide had equivalent outcomes and benefits. Cost per participant was under $100. DISCUSSION: A three-month, low-cost, self-facilitated series of dinner meetings for interprofessional clinical faculty decreased burnout and improved engagement, sense of connection to colleagues, and sense of departmental commitment to well-being. Structured discussion guides were not necessary to achieve benefit. This study broadens the possibilities for cost-effective opportunities to transform institutional culture and effectively enhance faculty well-being.

Building Your "Educational Peloton:" Cycling Together for Success During Uncertain Times.

ABSTRACT: Burnout is a pervasive concern that negatively impacts physicians, patients, and healthcare organizations. Stress, uncertainty, clinical demands, and rapidly changing teams threaten the learning environment, where connection is key to resilience. The COVID-19 pandemic amplifies these challenges. Building an "educational peloton" to provide a safe and protective educational community may help optimize learning and team performance. Easily implementable strategies include: (1) Maximize learning opportunities, particularly small ones; (2) Ensure quality feedback; and (3) Facilitate collegiality. Intentionally nurturing an "educational peloton"-especially during times of uncertainty and change-can help drive engagement and work satisfaction, which can improve patient safety and healthcare outcomes, as well as boost human connection and promote community.

Everyday Resilience: Equipping Faculty With Practical Exercises to Promote Resilience Among Medical Students.

Introduction: Burnout is prevalent in health care. As professionals advocate to increase resilience training as a strategy to reduce burnout, few examples exist of practical resilience programs that equip faculty to help students build and sustain well-being over time. Method: We developed two straightforward, skills-based resilience exercises. Breaking Down Easy taught individuals to identify personal strengths. My Resilience Practice helped individuals identify strategies to cope with daily stressors. We taught these exercises to international faculty in a train-the-trainer workshop format, at two medical education conferences. Faculty applied the exercises, performed pair-share reflections, and discussed opportunities to introduce the exercises in their own institutions. Postsession surveys evaluated the workshop quality and the exercises' ease of use and applicability. Results: Thirty-five faculty and five students participated across two international conferences. Of participants, 83% (33 of 40) completed postsession surveys. On a 5-point Likert scale, participants rated the workshop on average 4.4 for usefulness, 4.6 for applicability, 4.4 for ease of instruction, 4.5 for clarity, and 4.8 for overall quality. Participants found the exercises to be straightforward to use and planned to use them at their institutions with students, residents, and faculty. Discussion: Participants found our workshop to be relevant and effective and shared their intention to incorporate these materials into their teaching with medical students, residents, and faculty. Implementing effective programs to build resilience is critical to increasing well-being and reducing burnout. This, in turn, may enhance patient safety and improve health system outcomes.

A randomized experimental study to assess the effect of language on medical students' anxiety due to uncertainty.

Background Communication and handoff failures are common causes of diagnostic errors in hospital. Human quest for certainty can increase the likelihood of premature closure in decision-making, the most common phenomenon in misdiagnosis. Little research exists on whether language choice in handoffs affects physicians' sense of uncertainty. Methods Medical students from a large US medical school were randomized to receive one of four language variations describing a presumed diagnosis in hypothetical handoffs from emergency department (ED) to inpatient ward. The control language arm used the word 'diagnosis'; experimental arms replaced this word with either 'hypothesis', 'probability of 60%', or 'working diagnosis' with a short differential. Outcome measures were students' anxiety due to uncertainty (range 5-30; higher scores indicating higher stress from uncertainty) and clinical uncertainty about the ED provider's presumed diagnosis. Results Mean anxiety due to uncertainty was significantly higher in subjects receiving the 'hypothesis' language arm compared to those receiving the control 'diagnosis' language [19.2 (4.6) vs. 15.5 (3.4); p<0.008]. Differences between subjects who received the probability language [17.2 (5.8) vs. 15.5 (3.4); p=0.26] and 'working diagnosis' language [16 (5) vs. 15.5 (3.4); p=0.69] were not statistically significant. There was no difference in items assessing clinical uncertainty after each scenario. Conclusions The word 'hypothesis' increased anxiety due to uncertainty compared to the word 'diagnosis', but did not change assessments of clinical uncertainty. Further research is needed to assess how use of language in clinical handoffs may influence perceptions and anxiety related to uncertainty and whether optimal language can be identified that leads to recognition of uncertainty without maladaptive stress or anxiety due to uncertainty.

Association of Pediatric Resident Physician Depression and Burnout With Harmful Medical Errors on Inpatient Services.

PURPOSE: To determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians. METHOD: The authors conducted a prospective cohort study from 2011 to 2013 in seven pediatric academic medical centers in the United States and Canada. Resident physicians were screened for burnout and depression using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS). A two-step surveillance methodology, involving a research nurse and two physician reviewers, was used to measure and categorize errors. Bivariate and mixed-effects regression models were used to evaluate the relationship between burnout, depression, and rates of harmful, nonharmful, and total errors. RESULTS: A total of 388/537 (72%) resident physicians completed the MBI-HSS and HANDS surveys. Seventy-six (20%) and 178 (46%) resident physicians screened positive for depression and burnout, respectively. Screening positive for depression was associated with a 3.0-fold higher rate of harmful errors (incidence rate ratio = 2.99 [95% CI 1.40-6.36], P = .005). However, there was no statistically significant association between depression and total or nonharmful errors or between burnout and harmful, nonharmful, or total errors. CONCLUSIONS: Resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors. This association suggests resident physician mental health could be an important component of patient safety. If further research confirms resident physician depression increases the risk of harmful errors, it will become imperative to determine what interventions might mitigate this risk.

Cascades of Care After Incidental Findings in a US National Survey of Physicians.

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Stress From Uncertainty and Resilience Among Depressed and Burned Out Residents: A Cross-Sectional Study.

BACKGROUND: Depression and burnout are highly prevalent among residents, but little is known about modifiable personality variables, such as resilience and stress from uncertainty, that may predispose to these conditions. Residents are routinely faced with uncertainty when making medical decisions. OBJECTIVE: To determine how stress from uncertainty is related to resilience among pediatric residents and whether these attributes are associated with depression and burnout. METHODS: We surveyed 86 residents in pediatric residency programs from 4 urban freestanding children's hospitals in North America in 2015. Stress from uncertainty was measured with the use of the Physicians' Reaction to Uncertainty Scale, resilience with the use of the 14-item Resilience Scale, depression with the use of the Harvard National Depression Screening Scale; and burnout with the use of single-item measures of emotional exhaustion and depersonalization from the Maslach Burnout Inventory. RESULTS: Fifty out of 86 residents responded to the survey (58.1%). Higher levels of stress from uncertainty correlated with lower resilience (r = -0.60; P < .001). Five residents (10%) met depression criteria and 15 residents (31%) met burnout criteria. Depressed residents had higher mean levels of stress due to uncertainty (51.6 ± 9.1 vs 38.7 ± 6.7; P < .001) and lower mean levels of resilience (56.6 ± 10.7 vs 85.4 ± 8.0; P < .001) compared with residents who were not depressed. Burned out residents also had higher mean levels of stress due to uncertainty (44.0 ± 8.5 vs 38.3 ± 7.1; P = .02) and lower mean levels of resilience (76.7 ± 14.8 vs 85.0 ± 9.77; P = .02) compared with residents who were not burned out. CONCLUSIONS: We found high levels of stress from uncertainty, and low levels of resilience were strongly correlated with depression and burnout. Efforts to enhance tolerance of uncertainty and resilience among residents may provide opportunities to mitigate resident depression and burnout.

Training tomorrow's doctors.

The ability of our NHS to deliver world-class compassionate care is dependent on the quality of training and education of our staff. We know that the path of moving from novice to expert is far from linear. Instead, it is a complex journey that is domain specific with multiple variations reflecting the individuality of our learners. Within this complex journey, there is a need to train the doctors of tomorrow to be humanistic, competent, patient-centred, resilient beings who will thrive in a challenging environment, striving to advance medicine. We discuss two models of curricula, the longitudinal integrated programmes and the internal medicine curriculum, which are proposed to address the healthcare needs of the UK population. In this article, we look at the opportunities that exist, the future potentials for medical education, and the challenges to overcome as we endeavour to create the best education models for physicians in the 21st century.

Modifiable factors influencing relatives' decision to offer organ donation: systematic review.

OBJECTIVE: To identify modifiable factors that influence relatives' decision to allow organ donation. DESIGN: Systematic review. DATA SOURCES: Medline, Embase, and CINAHL, without language restriction, searched to April 2008. Review methods Three authors independently assessed the eligibility of the identified studies. We excluded studies that examined only factors affecting consent that could not be altered, such as donor ethnicity. We extracted quantitative results to an electronic database. For data synthesis, we summarised the results of studies comparing similar themes. RESULTS: We included 20 observational studies and audits. There were no randomised controlled trials. The main factors associated with reduced rates of refusal were the provision of adequate information on the process of organ donation and its benefits; high quality of care of potential organ donors; ensuring relatives had a clear understanding of brain stem death; separating the request for organ donation from notification that the patient had died; making the request in a private setting; and using trained and experienced individuals to make the request. CONCLUSIONS: Limited evidence suggests that there are modifiable factors in the process of requests for organ donation, in particular the skills of the individual making the request and the timing of this conversation, that might have a significant impact on rates of consent. Targeting these factors might have a greater and more immediate effect on the number of organs for donation than legislative or other long term strategies.