Difficulty sensitivity replaces reward sensitivity during adolescence: Task-related fMRI and functional connectivity during self-regulative learning choices.

AIM: We examined age-related differences in valuation and cognitive control circuits during value-based decision-making. METHODS: 13-year-olds (N = 25) and 17-year-olds (N = 22) made a metacognitive choice to be tested or not on an upcoming learning task, based on reward and difficulty associated with word-pairs. To investigate whether these determinants of subjective value are differently processed at different ages, we performed region-of-interest(ROI)-based analyses of task-related and functional connectivity data. RESULTS: We observed age-related differences in responsiveness of valuation structures (amygdala, ventral striatum, ventromedial prefrontal cortex) and caudate nucleus, with activity modulated by reward in 13-year-olds, while in 17-year-olds activity being responsive to difficulty. These accompanied age-related differences in functional connectivity between medial prefrontal and striatal/amygdala seeds. DISCUSSION: These results are in line with current views that sensitivity changes for reward and difficulty during adolescence are the result of a maturational switch in effort-related signalling in the cognitive control circuit, which increasingly regulates value-signalling structures.

In experts' words: Translating theory to practice for teaching self-regulated learning.

INTRODUCTION: Health professions education (HPE) should help students to competently self-regulate their learning, preparing them for future challenges. This study explored the perspectives of expert self-regulated learning (SRL) researchers and practitioners on the practical integration of SRL theories into teaching. METHODS: An exploratory qualitative research study was conducted involving semi-structured interviews with acknowledged research leaders in the field of SRL and/or experienced professionals dedicated to teaching SRL strategies for complex skills in different disciplines. The data were analyzed using an iterative thematic approach guided by a six-step framework. RESULTS: Fifteen interviews were conducted with experts from six countries representing diverse contexts, cultures, and disciplines. We identified five themes related to translating theory to practice for teaching SRL in HPE: theoretical issues, cultural aspects, stakeholders' participation, teaching complexity, assessment, and feedback. CONCLUSIONS: This study presents a useful starting point for teaching SRL. The experts suggest a supportive learning environment with the guidance of competent teachers by using general and task-specific teaching and learning strategies, as well as sufficient sources and cycles of feedback, all tailored to the culture and context. These findings call for a shift in faculty development programs to foster teachers to support second-order scaffolding in HPE.

Optimizing self-organized study orders: combining refutations and metacognitive prompts improves the use of interleaved practice.

During category learning, students struggle to create an optimal study order: They often study one category at a time (i.e., blocked practice) instead of alternating between different categories (i.e., interleaved practice). Several interventions to improve self-study of categorical learning have been proposed, but these interventions have only been tested in learning tasks where students did not create the study order themselves. Instead, they decided which type of study order to follow. This pre-registered experiment examined whether an intervention that combines refutations and metacognitive prompts can enhance students' engagement in interleaved practice, specifically when they organize the learning materials themselves. Ninety-one undergraduate students were randomized into the intervention and control condition and learned visual categories. Prior to the intervention, students used more blocked practice. After the intervention, the use of interleaved practice significantly increased in both immediate and delayed-transfer tasks. More interleaved practice was associated with better classification performance. Our findings indicate that refutations and metacognitive prompts form a strong intervention that corrects students' erroneous beliefs and increases their engagement in interleaved practice.

Librarian-Led Assessment of Medical Students' Evidence-Based Medicine Competency: Facilitators and Barriers.

Introduction: We must ensure, through rigorous assessment that physicians have the evidence-based medicine (EBM) skills to identify and apply the best available information to their clinical work. However, there is limited guidance on how to assess EBM competency. With a better understanding of their current role in EBM education, Health Sciences Librarians (HSLs), as experts, should be able to contribute to the assessment of medical student EBM competence. The purpose of this study is to explore the HSLs perspective on EBM assessment practices, both current state and potential future activities. Methods: We conducted focus groups with librarians from across the United States to explore their perceptions of assessing EBM competence in medical students. Participants had been trained to be raters of EBM competence as part of a novel Objective Structured Clinical Examination (OSCE). This OSCE was just the starting point and the discussion covered topics of current EBM assessment and possibility for expanded responsibilities at their own institutions. We used a reflexive thematic analysis approach to construct themes from our conversations. Results: We constructed eight themes in four broad categories that influence the success of librarians being able to engage in effective assessment of EBM: administrative, curricular, medical student, and librarian. Conclusion: Our results inform medical school leadership by pointing out the modifiable factors that enable librarians to be more engaged in conducting effective assessment. They highlight the need for novel tools, like EBM OSCEs, that can address multiple barriers and create opportunities for deeper integration of librarians into assessment processes.

Exploring the use of metacognitive monitoring cues following a diagram completion intervention.

Studying texts constitutes a significant part of student learning in health professions education. Key to learning from text is the ability to effectively monitor one's own cognitive performance and take appropriate regulatory steps for improvement. Inferential cues generated during a learning experience typically guide this monitoring process. It has been shown that interventions to assist learners in using comprehension cues improve their monitoring accuracy. One such intervention is having learners to complete a diagram. Little is known, however, about how learners use cues to shape their monitoring judgments. In addition, previous research has not examined the difference in cue use between categories of learners, such as good and poor monitors. This study explored the types and patterns of cues used by participants after being subjected to a diagram completion task prior to their prediction of performance (PoP). Participants' thought processes were studied by means of a think-aloud method during diagram completion and the subsequent PoP. Results suggest that relying on comprehension-specific cues may lead to a better PoP. Poor monitors relied on multiple cue types and failed to use available cues appropriately. They gave more incorrect responses and made commission errors in the diagram, which likely led to their overconfidence. Good monitors, on the other hand, utilized cues that are predictive of learning from the diagram completion task and seemed to have relied on comprehension cues for their PoP. However, they tended to be cautious in their judgement, which probably made them underestimate themselves. These observations contribute to the current understanding of the use and effectiveness of diagram completion as a cue-prompt intervention and provide direction for future research in enhancing monitoring accuracy.

Trainee selection of tasks in postgraduate medical education: Is there a role for 'cherry-picking' to optimise learning?

PURPOSE: Learning is optimised when postgraduate trainees engage in clinical tasks in their zone of proximal development (ZPD). However, workplace learning environments impose additional non-learning goals and additional tasks that may lead to trainees engaging in tasks that do not fall within their ZPD. We do not fully understand how trainees select clinical tasks in the workplace learning environment. If we knew the goals and factors they consider when selecting a task, we could better equip trainees with strategies to select tasks that maximise learning. We explored how postgraduate trainees select clinical tasks using echocardiography interpretation as a model. METHODS: Canadian General Cardiology residents and Echocardiography fellows were invited to participate in semi-structured interviews. Aligning with a theory-informed study, two independent researchers used a deductive, directed content analysis approach to identify codes and themes. RESULTS: Eleven trainees from seven Canadian universities participated (PGY4 = 4, PGY5 = 3, PGY6 = 1 and echocardiography fellows = 3). Goals included learning content, fulfilling assessment criteria and contributing to clinical demands. Trainees switched between goals throughout the day, as it was too effortful for them to engage in tasks within their ZPD at all times. When trainees had sufficient mental effort available, they selected higher complexity tasks that could advance learning content. When available mental effort was low, trainees selected less complex tasks that fulfilled numerically based assessment goals or contributed to clinical demands. Trainees predominantly used perceived complexity of the echocardiogram as a factor to select tasks to achieve their desired goals. CONCLUSION: Postgraduate trainees select tasks within their ZPD that enable them to maximise learning when they perceive to have sufficient mental effort available and workplace affordances are adequate. These findings can inform individual and systemic strategies to maximise learning when selecting tasks.

Twelve tips for applying the think-aloud method to capture cognitive processes.

The think-aloud method is an established technique for studying human thought (cognitive) processes. Problem-solving and decision-making are essential skills for medical professionals, and the cognitive processes underlying these skills are complex. Studying these thought processes would enable educators, clinicians, and researchers to modify or refine their approaches and interventions. The think-aloud method has been utilized for capturing cognitive processes in a variety of fields, including computer usability, sports and cognitive psychology. Medical education also recognizes thought processes as valuable data for research and education. This article aims to guide researchers and educators through the preparation and implementation of a think-aloud method to record participants' thought processes during an activity.

Basic psychological needs satisfaction as a mediator between clinical learning climate, self-regulated learning and perceived learning in the nursing education context.

PURPOSE: Self-regulated learning (SRL) can enhance students' learning process. Students need support to effectively regulate their learning. However, the effect of learning climate on SRL behavior, its ultimate effect on learning and the underlying mechanisms have not yet been established. We explored these relationships using self-determination theory. MATERIALS AND METHODS: Nursing students (N = 244) filled in questionnaires about SRL behavior, perceived learning, perceived pedagogical atmosphere and Basic Psychological Needs (BPN) satisfaction after their clinical placement. Structural equation modelling was used to test a model in which perceived pedagogical atmosphere affects SRL behavior and subsequent perceived learning through BPN satisfaction. RESULTS: The tested model had an adequate fit (RMSEA = 0.080, SRMR = 0.051; CFI = 0.972; TLI = 0.950). A positively perceived pedagogical atmosphere contributed to SRL behavior, which was fully explained by BPN satisfaction. SRL partially mediated the contribution of pedagogical atmosphere/BPN to perceived learning. CONCLUSIONS: A learning climate that satisfies students' BPN contributes to their SRL behavior. SRL behavior plays a positive but modest role in the relationship between climate and perceived learning. Without a culture that is supportive of learning, implementation of tools to apply SRL behavior may not be effective. Study limitations include reliance on self-report scales and the inclusion of a single discipline.

Understanding effort regulation: Comparing 'Pomodoro' breaks and self-regulated breaks.

BACKGROUND: During self-study, students need to monitor and regulate mental effort to replete working memory resources and optimize learning results. Taking breaks during self-study could be an effective effort regulation strategy. However, little is known about how breaktaking relates to self-regulated learning. AIMS: We investigated the effects of taking systematic or self-regulated breaks on mental effort, task experiences and task completion in real-life study sessions for 1 day. SAMPLE: Eighty-seven bachelor's and master's students from a Dutch University. METHODS: Students participated in an online intervention during their self-study. In the self-regulated-break condition (n = 35), students self-decided when to take a break; in the systematic break conditions, students took either a 6-min break after every 24-min study block (systematic-long or 'Pomodoro technique', n = 25) or a 3-min break after every 12-min study block (systematic-short, n = 27). RESULTS: Students had longer study sessions and breaks when self-regulating. This was associated with higher levels of fatigue and distractedness, and lower levels of concentration and motivation compared to those in the systematic conditions. We found no difference between groups in invested mental effort or task completion. CONCLUSIONS: Taking pre-determined, systematic breaks during a study session had mood benefits and appeared to have efficiency benefits (i.e., similar task completion in shorter time) over taking self-regulated breaks. Measuring how mental effort dynamically fluctuates over time and how effort spent on the learning task differs from effort spent on regulating break-taking requires further research.

Identifying characteristics of a skilled communicator in the clinical encounter.

BACKGROUND: In medical communication research, there has been a shift from 'communication skills' towards 'skilled communication', the latter implying the development of flexibility and creativity to tailor communication to authentic clinical situations. However, a lack of consensus currently exists what skilled communication entails. This study therefore aims to identify characteristics of a skilled communicator, hereby contributing to theory building in communication research and informing medical training. METHOD: In 2020, six nominal group technique (NGT) sessions were conducted in the context of the general practitioner (GP) training programme engaging 34 stakeholders (i.e. GPs, GP residents, faculty members and researchers) based on their experience and expertise in doctor-patient communication. Participants in each NGT session rank-ordered a 'Top 7' of characteristics of a skilled communicator. The output of the NGT sessions was analysed using mixed methods, including descriptive statistics and thematic content analysis during an iterative process. RESULTS: Rankings of the six sessions consisted of 191 items in total, which were organised into 41 clusters. Thematic content analysis of the identified 41 clusters revealed nine themes describing characteristics of a skilled communicator: (A) being sensitive and adapting to the patient; (B) being proficient in applying interpersonal communication; (C) self-awareness, learning ability and reflective capacity; (D) being genuinely interested; (E) being proficient in applying patient-centred communication; (F) goal-oriented communication; (G) being authentic; (H) active listening; and (I) collaborating with the patient. CONCLUSIONS: We conceptualise a skilled communication approach based on the identified characteristics in the present study to support learning in medical training. In a conceptual model, two parallel processes are key in developing adaptive expertise in communication: (1) being sensitive and adapting communication to the patient and (2) monitoring communication performance in terms of self-awareness and reflective capacity. The identified characteristics and the conceptual model provide a base to develop a learner-centred programme, facilitating repeated practice and reflection. Further research should investigate how learners can be optimally supported in becoming skilled communicators during workplace learning.

Study smart - impact of a learning strategy training on students' study behavior and academic performance.

Recent research shows the importance to teach students the self-regulated use of effective learning strategies at university. However, the effects of such training programs on students' metacognitive knowledge, use of learning strategies, and academic performance in the longer term are unknown. In the present study, all first-year pharmacology students from one university attended a learning strategy training program, i.e., the 'Study Smart program', in their first weeks. The 20% (n = 25) lowest scoring students on the first midterm received further support regarding their learning strategies. Results showed that all students gained accurate metacognitive knowledge about (in)effective learning strategies in the short- and long-term and reported to use less highlighting, less rereading, but more interleaving, elaboration, and distributed practice after the training program. Academic performance was compared to the prior cohort, which had not received the Study Smart program. While in the previous cohort, students in the top, middle, and bottom rank of midterm 1 stayed in these ranks and still differed significantly in the final exam, students in the Study Smart cohort that received the training program improved throughout the year and differences between ranks were significantly reduced. A learning strategy training program including a remediation track for lower performing students can thus support students to study more effectively and enhance equal chances for all students at university.

Dealing with Desirable Difficulties: Supporting Students to Accept, Reduce, or Silence Effort.

In this writing, I summarize the insights from my keynote lecture at the annual 2023 IAMSE Meeting in Cancún, Mexico, titled "Effort is the new smart. Supporting students in the self-regulated use of desirable difficulties." I explain how self-regulated learning is challenging for many students in higher education and even more so under learning conditions that create desirable difficulties: conditions that foster long-term learning and transfer of knowledge and skills, but that are generally more effortful to engage in. I describe how the intricate relation between perceived effort and perceived learning determines students' use of desirable difficulties. Finally, I outline promising interventional approaches academic teachers can employ to support students to seek out and engage in desirable difficulties.

Holistic processing only? The role of the right fusiform face area in radiological expertise.

Radiologists can visually detect abnormalities on radiographs within 2s, a process that resembles holistic visual processing of faces. Interestingly, there is empirical evidence using functional magnetic resonance imaging (fMRI) for the involvement of the right fusiform face area (FFA) in visual-expertise tasks such as radiological image interpretation. The speed by which stimuli (e.g., faces, abnormalities) are recognized is an important characteristic of holistic processing. However, evidence for the involvement of the right FFA in holistic processing in radiology comes mostly from short or artificial tasks in which the quick, 'holistic' mode of diagnostic processing is not contrasted with the slower 'search-to-find' mode. In our fMRI study, we hypothesized that the right FFA responds selectively to the 'holistic' mode of diagnostic processing and less so to the 'search-to-find' mode. Eleven laypeople and 17 radiologists in training diagnosed 66 radiographs in 2s each (holistic mode) and subsequently checked their diagnosis in an extended (10-s) period (search-to-find mode). During data analysis, we first identified individual regions of interest (ROIs) for the right FFA using a localizer task. Then we employed ROI-based ANOVAs and obtained tentative support for the hypothesis that the right FFA shows more activation for radiologists in training versus laypeople, in particular in the holistic mode (i.e., during 2s trials), and less so in the search-to-find mode (i.e., during 10-s trials). No significant correlation was found between diagnostic performance (diagnostic accuracy) and brain-activation level within the right FFA for both, short-presentation and long-presentation diagnostic trials. Our results provide tentative evidence from a diagnostic-reasoning task that the FFA supports the holistic processing of visual stimuli in participants' expertise domain.

Supported Independence: The Role of Supervision to Help Trainees Manage Uncertainty.

PURPOSE: Safe and effective supervised practice requires a negotiated partnership between trainees and their supervisors. Substantial work has explored how supervisors make judgments about trainees' readiness to safely engage in critical professional activities, yet less is known about how trainees leverage the support of supervisors when they perceive themselves to be at the limits of their abilities. The purpose of this study is to explore how trainees use supervisory support to navigate experiences of clinical uncertainty. METHOD: Using a constructivist grounded theory approach, the authors explored how novice emergency medicine trainees conceptualized the role of their supervisors during experiences of clinical uncertainty. They employed a critical incident technique to elicit stories from participants immediately following clinical shifts between July and September 2020, and asked participants to describe their experiences of uncertainty within the context of supervised practice. Using constant comparison, 2 investigators coded line-by-line and organized these stories into focused codes. The relationships between these codes were discussed by the research team, and this enabled them to theorize about the relationships between the emergent themes. RESULTS: Participants reported a strong desire for supported independence, where predictable and accessible supervisory structures enabled them to work semiautonomously through challenging clinical situations. They described a process of borrowing their supervisors' comfort during moments of uncertainty and mechanisms to strategically broadcast their evolving understanding of a situation to implicitly invoke (the right level of) support from their supervisors. They also highlighted challenges they faced when they felt insufficiently supported. CONCLUSIONS: By borrowing comfort from-or deliberately projecting their thinking to-supervisors, trainees aimed to strike the appropriate balance between independence for the purposes of learning and support to ensure safety. Understanding these strategic efforts could help educators to better support trainees in their growth toward self-regulation.

Changes and Adaptations: How University Students Self-Regulate Their Online Learning During the COVID-19 Pandemic.

During the COVID-19 (coronavirus disease 2019) pandemic, universities had to shift from face-to-face to emergency remote education. Students were forced to study online, with limited access to facilities and less contact with peers and teachers, while at the same time being exposed to more autonomy. This study examined how students adapted to emergency remote learning, specifically focusing on students' resource-management strategies using an individual differences approach. One thousand eight hundred university students completed a questionnaire on their resource-management strategies and indicators of (un)successful adaptation to emergency remote learning. On average, students reported being less able to regulate their attention, effort, and time and less motivated compared to the situation before the crisis started; they also reported investing more time and effort in their self-study. Using a k-means cluster analysis, we identified four adaptation profiles and labeled them according to the reported changes in their resource-management strategies: the overwhelmed, the surrenderers, the maintainers, and the adapters. Both the overwhelmed and surrenderers appeared to be less able to regulate their effort, attention, and time and reported to be less motivated to study than before the crisis. In contrast, the adapters appreciated the increased level of autonomy and were better able to self-regulate their learning. The resource-management strategies of the maintainers remained relatively stable. Students' responses to open-answer questions on their educational experience, coded using a thematic analysis, were consistent with the quantitative profiles. Implications about how to support students in adapting to online learning are discussed.

Skeptical self-regulation: Resident experiences of uncertainty about uncertainty.

OBJECTIVES: Managing uncertainty is central to expert practice, yet how novice trainees navigate these moments is likely different than what has been described by experienced clinicians. Exploring trainees' experiences with uncertainty could therefore help explicate the unique cues that they attend to, how they appraise their comfort in these moments and how they enact responses within the affordances of their training environment. METHODS: Informed by constructivist grounded theory, we explored how novice emergency medicine trainees experienced and managed clinical uncertainty in practice. We used a critical incident technique to prompt participants to reflect on experiences with uncertainty immediately following a clinical shift, exploring the cues they attended to and the approaches they used to navigate these moments. Two investigators coded line-by-line using constant comparison, organising the data into focused codes. The research team discussed the relationships between these codes and developed a set of themes that supported our efforts to theorise about the phenomenon. RESULTS: We enrolled 13 trainees in their first two years of postgraduate training across two institutions. They expressed uncertainty about the root causes of the patient problems they were facing and the potential management steps to take, but also expressed a pervasive sense of uncertainty about their own abilities and their appraisals of the situation. This, in turn, led to challenges with selecting, interpreting and using the cues in their environment effectively. Participants invoked several approaches to combat this sense of uncertainty about themselves, rehearsing steps before a clinical encounter, checking their interpretations with others and implicitly calibrating their appraisals to those of more experienced team members. CONCLUSIONS: Trainees' struggles with the legitimacy of their interpretations impact their experiences with uncertainty. Recognising these ongoing struggles may enable supervisors and other team members to provide more effective scaffolding, validation and calibration of clinical judgments and patient management.

Warning bells: How clinicians leverage their discomfort to manage moments of uncertainty.

OBJECTIVES: It remains unclear how medical educators can more effectively bridge the gap between trainees' intolerance of uncertainty and the tolerance that experienced physicians demonstrate in practice. Exploring how experienced clinicians experience, appraise and respond to discomfort arising from uncertainty could provide new insights regarding the kinds of behaviours we are trying to help trainees achieve. METHODS: We used a constructivist grounded theory approach to explore how emergency medicine faculty experienced, managed and responded to discomfort in settings of uncertainty. Using a critical incident technique, we asked participants to describe case-based experiences of uncertainty immediately following a clinical shift. We used probing questions to explore cognitive, emotional and somatic manifestations of discomfort, how participants had appraised and responded to these cues, and how they had used available resources to act in these moments of uncertainty. Two investigators coded the data line by line using constant comparative analysis and organised transcripts into focused codes. The entire research team discussed relationships between codes and categories, and developed a conceptual framework that reflected the possible relationships between themes. RESULTS: Participants identified varying levels of discomfort in their case descriptions. They described multiple cues alerting them to problems that were evolving in unexpected ways or problems with aspects of management that were beyond their abilities. Discomfort served as a trigger for participants to monitor a situation with greater attention and to proceed more intentionally. It also served as a prompt for participants to think deliberately about the types of human and material resources they might call upon strategically to manage these uncertain situations. CONCLUSIONS: Discomfort served as a dynamic means to manage and respond to uncertainty. To be 'tolerant' of uncertainty thus requires clinicians to embrace discomfort as a powerful tool with which to grapple with the complex problems pervasive in clinical practice.

Undergraduate Radiology Education During the COVID-19 Pandemic: A Review of Teaching and Learning Strategies [Formula: see text].

The Coronavirus disease 2019 (COVID-19) pandemic has altered how medical education is delivered, worldwide. Didactic sessions have transitioned to electronic/online platforms and clinical teaching opportunities are limited. These changes will affect how radiology is taught to medical students at both the pre-clerkship (ie, year 1 and 2) and clinical (ie, year 3 and 4) levels. In the pre-clerkship learning environment, medical students are typically exposed to radiology through didactic lectures, integrated anatomy laboratories, case-based learning, and ultrasound clinical skills sessions. In the clinical learning environment, medical students primarily shadow radiologists and radiology residents and attend radiology resident teaching sessions. These formats of radiology education, which have been the tenets of the specialty, pose significant challenges during the pandemic. This article reviews how undergraduate radiology education is affected by COVID-19 and explores solutions for teaching and learning based on e-learning and blended learning theory.

Thinking fast or slow? Functional magnetic resonance imaging reveals stronger connectivity when experienced neurologists diagnose ambiguous cases.

For ∼40 years, thinking about reasoning has been dominated by dual-process theories. This model, consisting of two distinct types of human reasoning, one fast and effortless and the other slow and deliberate, has also been applied to medical diagnosis. Medical experts are trained to diagnose patients based on their symptoms. When symptoms are prototypical for a certain diagnosis, practitioners may rely on fast, recognition-based reasoning. However, if they are confronted with ambiguous clinical information slower, analytical reasoning is required. To examine the neural underpinnings of these two hypothesized forms of reasoning, 16 highly experienced clinical neurologists were asked to diagnose two types of medical cases, straightforward and ambiguous cases, while functional magnetic resonance imaging was being recorded. Compared with reading control sentences, diagnosing cases resulted in increased activation in brain areas typically found to be active during reasoning such as the caudate nucleus and frontal and parietal cortical regions. In addition, we found vast increased activity in the cerebellum. Regarding the activation differences between the two types of reasoning, no pronounced differences were observed in terms of regional activation. Notable differences were observed, though, in functional connectivity: cases containing ambiguous information showed stronger connectivity between specific regions in the frontal, parietal and temporal cortex in addition to the cerebellum. Based on these results, we propose that the higher demands in terms of controlled cognitive processing during analytical medical reasoning may be subserved by stronger communication between key regions for detecting and resolving uncertainty.

"I Was Worried About the Patient, but I Wasn't Feeling Worried": How Physicians Judge Their Comfort in Settings of Uncertainty.

PURPOSE: Clinical educators often raise concerns that learners are not comfortable with uncertainty in clinical work, yet existing literature provides little insight into practicing clinicians' experiences of comfort when navigating the complex, ill-defined problems pervasive in practice. Exploring clinicians' comfort as they identify and manage uncertainty in practice could help us better support learners through their discomfort. METHOD: Between December 2018 and April 2019, the authors employed a constructivist grounded theory approach to explore experiences of uncertainty in emergency medicine faculty. The authors used a critical incident technique to elicit narratives about decision making immediately following participants' clinical shifts, exploring how they experienced uncertainty and made real-time judgments regarding their comfort to manage a given problem. Two investigators analyzed the transcripts, coding data line-by-line using constant comparative analysis to organize narratives into focused codes. These codes informed the development of conceptual categories that formed a framework for understanding comfort with uncertainty. RESULTS: Participants identified multiple forms of uncertainty, organized around their understanding of the problems they were facing and the potential actions they could take. When discussing their comfort in these situations, they described a fluid, actively negotiated state. This state was informed by their efforts to project forward and imagine how a problem might evolve, with boundary conditions signaling the borders of their expertise. It was also informed by ongoing monitoring activities pertaining to patients, their own metacognitions, and their environment. CONCLUSIONS: The authors' findings offer nuances to current notions of comfort with uncertainty. Uncertainty involved clinical, environmental, and social aspects, and comfort dynamically evolved through iterative cycles of forward planning and monitoring.