Development and Validation of a Scoring Rubric for Editorial Evaluation of Peer-review Quality: A Pilot Study.

Introduction: Despite the importance of peer review to publications, there is no generally accepted approach for editorial evaluation of a peer review's value to a journal editor's decision-making. The graduate medical education editors of the Western Journal of Emergency Medicine Special Issue in Educational Research & Practice (Special Issue) developed and studied the holistic editor's scoring rubric (HESR) with the objective of assessing the quality of a review and an emphasis on the degree to which it informs a holistic appreciation for the submission under consideration. Methods: Using peer-review guidelines from several journals, the Special Issue's editors formulated the rubric as descriptions of peer reviews of varying degree of quality from the ideal to the unacceptable. Once a review was assessed by each editor using the rubric, the score was submitted to a third party for blinding purposes. We compared the performance of the new rubric to a previously used semantic differential scale instrument. Kane's validity framework guided the evaluation of the new scoring rubric around three basic assumptions: improved distribution of scores; relative consistency rather than absolute inter-rater reliability across editors; and statistical evidence that editors valued peer reviews that contributed most to their decision-making. Results: Ninety peer reviews were the subject of this study, all were assessed by two editors. Compared to the highly skewed distribution of the prior rating scale, the distribution of the new scoring rubric was bell shaped and demonstrated full use of the rubric scale. Absolute agreement between editors was low to moderate, while relative consistency between editor's rubric ratings was high. Finally, we showed that recommendations of higher rated peer reviews were more likely to concur with the editor's formal decision. Conclusion: Early evidence regarding the HESR supports the use of this instrument in determining the quality of peer reviews as well as its relative importance in informing editorial decision-making.

'Walking together': How relationships shape physicians' clinical reasoning.

INTRODUCTION: The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning. METHODS: Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest. RESULTS: The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts. CONCLUSION: Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.

A Collaborative Approach to Mentored Peer Reviews Sponsored by the Council of Residency Directors in Emergency Medicine.

Introduction: Historically, there have been no systematic programs for teaching peer review, leaving trainees to learn by trial and error. Recently, a number of publications have advocated for programs where experienced reviewers mentor trainees to more efficiently acquire this knowledge. Objective: Our goal was to develop an introductory learning experience that intentionally fosters peer-review skills. Methods: The Council of Residency Directors in Emergency Medicine (CORD) offered education fellowship directors the opportunity to mentor their fellows by reviewing submitted manuscript(s) supplemented by educational material provided by their journal. Reviews were collaboratively created. The decision letter that was sent to manuscript authors was also sent to the mentees; it included all reviewers' and editor's comments, as feedback. In 2022, fellows received a post-experience survey regarding prior experiences and their perspectives of the mentored peer-review experience. Results: From 2020-2022, participation grew from 14 to 30 education fellowships, providing 76 manuscript peer reviews. The 2022 survey-response rate of 87% (20/23) revealed that fellows were inexperienced in education scholarship prior to participation: 30% had authored an education paper, and 10% had performed peer review of an education manuscript. Overall, participants were enthusiastic about the program and anxious to participate the following year. In addition, participants identified a number of benefits of the mentored experience including improved understanding of the scholarship process; informing fellows' scholarly pursuits; improved conceptualization of concepts learned elsewhere in training; and learning through exposure to scholarship. Conclusion: This program's early findings suggest that collaboration between academic societies and interested graduate medical education faculty has the potential to formalize the process of learning peer review, benefitting all involved stakeholders.

'Yourself in all your forms': A grounded theory exploration of identity safety in medical students.

INTRODUCTION: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. METHODS: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. RESULTS: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. DISCUSSION: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

Professional identity struggle and ideology: A qualitative study of residents' experiences.

INTRODUCTION: To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency. METHODS: We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings. RESULTS: We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals. CONCLUSION: This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Fostering Adaptive Expertise Through Simulation.

Technology-enhanced simulation has been used to tackle myriad challenges within health professions education. Recently, work has typically adopted a mastery learning orientation that emphasizes trainees' sequential mastery of increasingly complex material. Doing so has privileged a focus on performance and task completion, as captured by trainees' observable behaviors and actions. Designing simulation in these ways has provided important advances to education, clinical care, and patient safety, yet also placed constraints around how simulation-based activities were enacted and learning outcomes were measured. In tracing the contemporary manifestations of simulation in health professions education, this article highlights several unintended consequences of this performance orientation and draws from principles of adaptive expertise to suggest new directions. Instructional approaches grounded in adaptive expertise in other contexts suggest that uncertainty, struggle, invention, and even failure help learners to develop deeper conceptual understanding and learn innovative approaches to novel problems. Adaptive expertise provides a new lens for simulation designers to think intentionally around how idiosyncrasy, individuality, and inventiveness could be enacted as central design principles, providing learners with opportunities to practice and receive feedback around the kinds of complex problems they are likely to encounter in practice. Fostering the growth of adaptive expertise through simulation will require a fundamental reimagining of the design of simulation scenarios, embracing the power of uncertainty and ill-defined problem spaces, and focusing on the structure and pedagogical stance of debriefing. Such an approach may reveal untapped potential within health care simulation.

From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout.

PURPOSE: Despite the recognized importance of collaborative communication among physicians, conflict at transitions of care remains a pervasive issue. Recent work has underscored how poor communication can undermine patient safety and organizational efficiency, yet little is known about how interphysician conflict (I-PC) impacts the physicians forced to navigate these tensions. The goal of this study was to explore the social processes and interpersonal interactions surrounding I-PC and their impact, using conversations regarding admission between internal medicine (IM) and emergency medicine (EM) as a lens to explore I-PC in clinical practice. METHOD: The authors used constructivist grounded theory to explore the interpersonal and social dynamics of I-PC. They used purposive sampling to recruit participants, including EM resident and attending physicians and IM attending physicians. The authors conducted hour-long, semistructured interviews between June and October 2020 using the Zoom video conferencing platform. Interviews were coded in 3 phases: initial line-by-line coding, focused coding, and recording. Constant comparative analysis was used to refine emerging codes, and the interview guide was iteratively updated. RESULTS: The authors interviewed 18 residents and attending physicians about how engaging in I-PC led to both personal and professional harm. Specifically, physicians described how I-PC resulted in emotional distress, demoralization, diminished sense of professional attributes, and job dissatisfaction. Participants also described how emotional residue attached to past I-PC events primed the workplace for future conflict. CONCLUSIONS: I-PC may represent a serious yet underrecognized source of harm, not only to patient safety but also to physician well-being. Participants described both the personal and professional consequences of I-PC, which align with the core tenets of burnout. Burnout is a well-established threat to the physician workforce, but unlike many other contributors to burnout, I-PC may be modifiable through improved education that equips physicians with the skills to navigate I-PC throughout their careers.

"Not just a checkbox": A qualitative study of the resident scholarly experience.

Objectives: Scholarship is a requirement of residency training; however, the scholarly productivity of trainees is highly variable. The purpose of this study was to explore the perspectives of residents who have been highly productive in scholarship. Methods: We performed a qualitative study using a constructivist-interpretivist paradigm and conducted semistructured interviews at seven Accreditation Council for Graduate Medical Education-accredited emergency medicine residency programs in the United States. We included sites of diverse locations and training formats (PGY-1 to -4 vs. PGY-1 to -3). Program leadership identified residents with high levels of scholarly productivity at their institutions. We used purposive sampling to seek out residents with diversity in gender and PGY level. Two researchers independently performed a thematic analysis of interview transcripts. Discrepancies were resolved through in-depth discussion and negotiated consensus. Results: We invited 14 residents and all consented to be interviewed. Residents felt scholarship enhanced their knowledge and skills, grew collaborative networks, and provided personal fulfillment and external rewards. Scholarship positively impacted their careers by focusing their professional interests and informing career decisions. Participants identified individual and institutional facilitators of success including personal prior knowledge and skills, project management skills, mindset, protected time, mentorship, and leadership support. Challenges to conducting scholarship included lack of time, expertise, and resources. Participants acknowledged that participating in scholarly activities was hard work and recommended that residents seek out quality mentorship, work on projects that they are passionate, start early, and be persistent in their efforts. Participants' advice to faculty supporting resident scholarship included recommendations to allow resident autonomy of projects, provide scholarly opportunities, and be responsive to trainee needs. Conclusions: Participants in this study highlighted benefits of participating in scholarly activity as well as challenges and strategies for success. These results can inform residencies seeking to enhance the scholarly experience of trainees.

An Ecological Account of Clinical Reasoning.

PURPOSE: The prevailing paradigms of clinical reasoning conceptualize context either as noise that masks, or as external factors that influence, the internal cognitive processes involved in reasoning. The authors reimagined clinical reasoning through the lens of ecological psychology to enable new ways of understanding context-specific manifestations of clinical performance and expertise, and the bidirectional ways in which individuals and their environments interact. METHOD: The authors performed a critical review of foundational and current literature from the field of ecological psychology to explore the concepts of clinical reasoning and context as presented in the health professions education literature. RESULTS: Ecological psychology offers several concepts to explore the relationship between an individual and their context, including affordance, effectivity, environment, and niche. Clinical reasoning may be framed as an emergent phenomenon of the interactions between a clinician's effectivities and the affordances in the clinical environment. Practice niches are the outcomes of historical efforts to optimize practice and are both specialty-specific and geographically diverse. CONCLUSIONS: In this framework, context specificity may be understood as fundamental to clinical reasoning. This changes the authors' understanding of expertise, expert decision making, and definition of clinical error, as they depend on both the expert's actions and the context in which they acted. Training models incorporating effectivities and affordances might allow for antiableist formulations of competence that apply learners' abilities to solving problems in context. This could offer both new means of training and improve access to training for learners of varying abilities. Rural training programs and distance education can leverage technology to provide comparable experience to remote audiences but may benefit from additional efforts to integrate learners into local practice niches.

Publishing your scholarship: a survey of pearls from top reviewers.

Experts have described ways to improve peer review quality. Perspectives from expert reviewers are largely absent in the health professions education literature. To gather guidance from expert reviewers, to aid authors striving to publish and reviewers aiming to perform their task effectively. This study surveyed the Journal of Graduate Medical Education (JGME) 'Top Reviewers' from 2017, 2018, and 2019. 'Top Reviewers' perform four or more reviews per year, with high average ratings. Top reviewers were sent an 11-item survey in February 2020. The survey included three demographic questions and eight open-ended, free-text questions about the concepts reviewers most often target in their reviews. We calculated descriptive statistics and performed a thematic analysis of open-ended responses. Of 62 eligible top reviewers, 44 (71%) responded to the survey. Only eight (18.2%) and seven (15.9%) respondents reported having 'stock phrases' or a reviewer template used for reviewer feedback to authors, respectively. The what (research question, methods), how (presentation, writing), and why (relevance, impact) were the resulting themes summarizing how reviewers categorized and responded to common problems. For 'really good papers' reviewers found the what acceptable and focused on how and why. For 'really bad' papers, reviewers focused on big picture feedback, such as the value of the study. Top reviewers from a single health professions education journal appear to have similar approaches to conducting reviews. While most do not use stock phrases or templates, they share similar strategies to differentiate 'good' vs. 'bad' papers through the what, why, and how of a manuscript.

Who's on your team? Specialty identity and inter-physician conflict during admissions.

PURPOSE: Despite the implementation of professionalism curricula and standardised communication tools, inter-physician conflict persists. In particular, the interface between emergency medicine (EM) and internal medicine (IM) has long been recognised as a source of conflict. The social nuances of this conflict remain underexplored, limiting educators' ability to comprehensively address these issues in the clinical learning environment. Thus, the authors explored EM and IM physicians' experiences with negotiating hospital admissions to better understand the social dynamics that contribute to inter-physician conflict and provide foundational guidance for communication best practices. METHODS: Using a constructivist grounded theory (CGT) approach, the authors conducted 18 semi-structured interviews between June and October 2020 with EM and IM physicians involved in conversations regarding admissions (CRAs). They asked participants to describe the social exchanges that influenced these conversations and to reflect on their experiences with inter-physician conflict. Data collection and analysis occurred iteratively. The relationships between the codes were discussed by the research team with the goal of developing conceptual connections between the emergent themes. RESULTS: Participants described how their approaches to CRAs were shaped by their specialty identity, and how allegiance to members of their group contributed to interpersonal conflict. This conflict was further promoted by a mutual sense of disempowerment within the organisation, misaligned expectations, and a desire to promote their group's prerogatives. Conflict was mitigated when patient care experiences fostered cross-specialty team formation and collaboration that dissolved traditional group boundaries. CONCLUSIONS: Conflict between EM and IM physicians during CRAs was primed by participants' specialty identities, their power struggles within the broader organisation, and their sense of duty to their own specialty. However, formation of collaborative inter-specialty physician teams and expansion of identity to include colleagues from other specialties can mitigate inter-physician conflict.

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.

A Piercing Diagnosis - Occult Foreign Body as the Cause of Acute Inguinal Pain.

CASE PRESENTATION: A 35-year-old woman presented to the emergency department with severe right inguinal pain. Her medical history was non-contributory and there was no known trauma or injury to the region. Amid concern for an incarcerated inguinal hernia, a computed tomography was obtained revealing a linear foreign body (FB) lateral to the femoral vessels. The FB was removed without complication at bedside and found to be a beading needle likely occultly lodged three days prior. DISCUSSION: Occult inguinal FBs are rare but can lead to deep venous thrombosis or pulmonary embolism if in or near vessels. By nature of being occult, an absence of ingestion, insertion, or penetrative history should not preclude consideration of a FB etiology. Computed tomography imaging is crucial in determining the urgency of, and approach to, inguinal foreign body removal.

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.

Spinal Arteriovenous Fistula, A Manifestation of Hereditary Hemorrhagic Telangiectasia: A Case Report.

INTRODUCTION: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by arteriovenous malformations (AVM). HHT can have neurological manifestations. CASE REPORT: A 32-year-old woman with a history of HHT presented to the emergency department with acute partial paralysis of the right leg, urinary retention, and right-sided back and hip pain. Magnetic resonance imaging of the spine demonstrated multiple, dilated blood vessels along the cervical spine, diffuse AVMs in the lumbar and thoracic spine, and a new arteriovenous fistula at the twelfth thoracic (T12) vertebral level. Her symptoms improved after endovascular embolization of the fistula. CONCLUSION: Spinal AVMs are thought to be more prevalent in patients with HHT. Given the high morbidity of arteriovenous fistulas, early recognition and intervention are critical.

"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.