News and Commentary The Future is Uncertain: Towards A Curriculum for Uncertainty in Clinical Practice

If there is one thing the COVID-19 pandemic has taught us, it’s that complexity and uncertainty abound in healthcare. Ironically, education and training in the health professions have traditionally taken place in the context of certainty. For example, students are typically assessed through methods that either have a single correct answer or a series of acceptable answers — consider multiple-choice examinations or objective structured clinical examinations. The traditional emphasis on linear thinking in health professions training has the potential to hinder students’ ability to appraise and navigate uncertainty and stymie creative problem-solving — skills needed to thrive in today’s clinical learning environment.

As our students transition from the classroom into the clinical environment, uncertainty becomes palpable and presents several struggles — struggles with making a diagnosis, managing complex diseases, communicating with patients, and coordinating care. Students’ relationships with uncertainty impacts communication with patients, decision-making ability, and resource management (e.g., diagnostic testing and/or consultations) at the point of care. Students poorly equipped with skills to navigate uncertainty can suffer from diminished self-efficacy (i.e., the confidence needed to accomplish their goals), erosion of empathy, and eventual burnout. Now more than ever, there is a need for formal training that prepares our learners for the uncertainties of clinical practice — training that will equip them with skills to appraise and navigate this uncertainty. Reflecting on lessons learned during the pandemic can provide meaningful insights into how curricula can better prepare trainees for clinical practice.

When there is a high degree of complexity, the relationship between cause and effect is not always clear, often making it difficult for clinical teams to navigate uncertain situations. The pandemic continues to serve as a case study of heightened complexity in this unique workplace. During the early stages of the pandemic, for example, as the demand for health services increased exponentially, clinicians were forced to adapt and re-adapt to rapidly evolving guidelines, when correct and/or absolute solutions were not readily available. Staffing shortages, scarcity of personal protective equipment, and the urgent need for infection control and prevention training only added to the uncertainty that challenged clinicians.

The good news is that opportunities for curricular development that prepare students for this uncertainty exist. Incorporation of the liberal arts, humanities programs, and patient-centered narratives into formal curriculum have been shown to improve students’ abilities to think laterally. Discussing the “philosophy of medicine” within clinical coursework can provide trainees with the familiarity to appraise and describe the uncertainty they are experiencing. The deliberate practice of communicating diagnostic uncertainty to patients, when a diagnosis to explain a patient’s symptoms is unknown, can prepare trainees for challenging, emotionally charged conversations. Similarly, coursework in Health Systems Science (HSS) is uniquely poised to introduce students to this uncertainty.

HSS offers a set of competencies related to value-based care, population health, interprofessional collaboration, health system improvement, and systems thinking. Reconciling the uncertainty that is part of clinical practice is not its own class or field of study; rather, it is a theme that is integrated across all HSS competencies. An understanding of HSS can equip students with the ability to appraise and/or diagnose the uncertainty they may encounter in clinical practice, which may be helpful in identifying next steps and strategies (for example, is a specific course of action for a specific clinical context a “knowable” or “unknowable” uncertainty). Similarly, HSS deliberately exposes students to cognitive science and raises their awareness of the patterns that are likely to come into play during times of uncertainty, such as prematurely making an inappropriate intervention or misdiagnosis that frequently arises from one’s biases and/or craving for a sense of certainty.

It’s vital that we integrate curricula that can help students make sense of — and take action amidst — the heightened uncertainty they will encounter in practice. In clinical situations that will change dynamically, as was witnessed, for example, with the rapid integration of virtual delivery of healthcare services during the pandemic to adapt to physical distancing requirements, clinicians will benefit from a framework to guide their ability to learntogether within the context of uncertainty and collaboratively develop novel solutions as they probe the system, make sense of it, and learn from it before they respond. To an extent, this is a practice we already routinely observe in quality improvement patient safety initiatives that leverage iterative PDSA (Plan, Do, Study, Act) cycles of improvement. The Cynefin framework, first introduced by David Snowden, has been offered as a framework that can help teams to make sense of their experiences as they work through uncertainty. HSS can borrow elements of this framework and equip learners with skills in problem-solving, such as being able to facilitate open, interactive communication that can help share ideas, such as critical incident debriefings, or generate and ask higher-order, divergent questions (e.g., ‘what if we’ or ‘how might we’ questions) during times of uncertainty. 

Fundamentally, training in health professions education should highlight the uncertainty that is intrinsic to clinical practice and openly embrace it, rather than trying to eliminate it in curricula. Frameworks borrowed from complexity science can serve as tools to help clinicians better define uncertainty, better identify strategies to deal with this uncertainty in the clinical environment, and avoid using reductionist approaches to complex situations. Similarly, we have opportunities to leverage the humanities, as well as innovative problem-solving in formal curricula to better prepare trainees for the complexity and uncertainty that lie ahead.

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