Using the structured content approach, we were able to describe 4 themes within the students’ essays that discuss uncertainty and ambiguity. Applying the 10 items described by Mezirow:
A. The circumstance under which the student encounters ambiguity and uncertainty is Mezirow’s “disorienting dilemma”.
B. The students’ reactions are the “self-reflection, critical assessment of assumptions, exploration of options for new roles, relationships and action.”
C. T he students’ “toolbox” of strategies to cope with the ambiguous situation and their own uncertainty is “planning a course of action, building competence"
D. There follows reintegration based on new perspective.
A. DISORIENTING DILEMMA
The disorienting dilemmas occurred when the clerk encountered clinical ambiguity in patients’ diagnosis, treatment, and/or prognosis. The disorienting dilemma, in part may have resulted from previously held assumptions. Clerkship year may be the first time they are confronted with the “vastness of the gap in where [they] currently [are] and where [they] want to be.” Through working with patients in a clinical setting, students find that “life as a student professional is no longer simply an academic exercise.” In transitioning from a purely academic classroom to the wards, they are confronted with certain truths: “medicine isn’t black and white,” “life isn’t fair,” among others. Patients do not present like neat and tidy multiple-choice questions, and they learn the full meaning of “patient’s do not read the textbook.” These common sayings all point to a broader discomfort and internal tension that results from clinical uncertainty. On a simpler basis, some students discuss awkwardness with not knowing how to communicate with patients and discover that patients often expect answers.
Clerkship is the disorienting dilemma
“When I began medical school, pre-clerkship (in my opinion) was straight forward...The task was clear, study the material the school provides, I’m then tested on said material and the world is easy. However, with clerkship changing that dynamic, there is no set material from which to master. I struggled initially, particularly in my first round, on coming up with a study plan that was realistic”
Medicine is an art
“There is no textbook way to do things, medicine it artful and scientific and while I am excited I am also terrified to hone my craft.”
“It wasn’t until clerkship year, ... I realized that medicine is one big educated guess.”
Patients don’t read the textbook
“Patients rarely present like a NBME style question, and I struggled with connecting the dots between patient stories, physical exam findings, differential diagnoses, and insurance coding.”
“My hands would start sweating and I would start thinking of the different differentials based on the nurse’s initial interview that I could report to my preceptor. This nervousness stemmed from my lack of patient interaction and the difficult encounters I had with some of the simulation patients during pre-clerkships. ...Going into clerkships, I thought real patients also would be like the simulated patients and not open up unless I asked questions in a specific way.”
B. STUDENT REACTIONS: TRANSFORMATIVE LEARNING
In our data set, we found that students reacted to the disorienting dilemma through transformative learning. The transformative learning occurred when the student discovered and dealt with the ambiguity and uncertainty through various metacognitive processes. Uncertainty forced some students to deeply reflect on their self-identity and how they approach problem solving. While some students adopted a more algorithmic style of thinking towards patients and disease processes, others found that algorithmic processes did not always apply to a given situation and could not replace clinical reasoning. Many students discussed the utility of the differential, a concept that they had been taught in pre-clerkship setting but did not completely understand how to use until clerkship. Students additionally developed a larger understanding of the concept of team of healthcare providers and learned that “patient care is not solely carried out by the physician,” but rather includes nurses, medics, techs, social workers, and other healthcare professionals. As one student writes, “it is impossible to be all knowing when it comes to medicine, and much of being a physician is working as a team and figuring it out.” Although many students reacted to uncertainty through changing the way they thought, some found that uncertainty led to worsened self-image and began to question their own intellectual adequacy. However, for some students,, uncertainty shaped the way they saw themselves and found that it was okay to admit that they did not always know the answer. In dealing with clinical uncertainty, some students spoke about a change in perspective. In regards to dealing with a case of nonaccidental trauma, one student writes “Learning to deal with situations like this has taught me a great deal about being a good provider as well as broadened my approach to life. I learned that although we want to interject our strong emotions into the situation of abuse, that is not our role.”
Introspection
“Since beginning clerkships, I have found myself examining my thoughts, actions, and words more often than I have in the past.”
“Coming out of pre-clerkship, creating differential diagnoses was a weakness of mine. I was not motivated to practice this skill because I thought to myself, if I get the question right and know the diagnosis, why does the other stuff matter? It’s still a working progress, but I am more motivated now because I understand that it’s not about getting the answer right. The goal is to create comprehensive care for our patient which can only be done if we include the possibility that we are wrong and that we are prepared to swiftly correct our mistakes.”
Change in self identity
“I continue to ask myself, in these last 12 months: is it WORTH it? Should I consider another path? Is it reasonable to ask this question to myself? Are others asking the same question? Is the nobility of profession, and the ability to help others in this art of medicine worth sacrificing the many years of my life I have begun to shave off at the back end with my stress, weight gain, poor sleep and lack of family interaction?”
Algorithm
“There are evidence-based ways of handling many of the patient’s symptoms but there is no algorithm to treating the patient as a whole or making the most of the time she and her parents have left together.”
C. STRATEGIES
The “toolbox” of strategies was developed by students as ways to cope with and hopefully combat uncertainty. The strategies included trusting the process of medical education, accepting responsibility of lifelong learning, learning how to use outside resources, and how to better communicate with patients to cope with uncertainty. They acquired skills needed to form the differential, such as asking the right questions, completing a thorough history and physical, understanding pathophysiology, and learning how to properly collect and synthesize information. The differential diagnosis was seen as an “educated guess” rather than an absolute truth and was a document to be reworked as new information became available. They learned to use outside resources such as guidelines, outside reading material, and how to better utilize the team of healthcare providers. Communication strategies developed, and some students learned how to admit “I don’t know” to patients as well as to staff. Some students started to shift to a patient centered outlook.
Communication
“I became much more comfortable with the response 'I am not sure but I will look it up and get back to you.'”
Modeling senior staff
“I realized that even the attending physicians constantly are learning…”
Trust the process
“Since starting clerkship and preparing for the shelf exams I’ve learned the universe of medical knowledge far exceeds anything that I could hope to cram into my head to prepare for some exam. I am better at accepting that and realizing that it doesn’t mean I’m behind or I’m not good enough to be a physician. It means that becoming a physician is a process—a very long one, likely unequaled in any other profession. But there is a process and I’m on track and I need to trust the process.”
Use outside resources such as guidelines
“Lately l feel that a concept I’ve been able to understand better is the function of guidelines and the importance of the education we get as physicians. For instance, yesterday I reviewed GBS+ status in mother of newborns yesterday and how we have guidelines that are helpful but do not cover every situation that we will encounter and how basic science allows us to make clinical decisions that would otherwise be very difficult to make...”
D. INTEGRATION
Students used the strategies they had developed, integrating them into their daily practice of medicine and into their reasoning patterns. They became “consciously competent” in dealing with clinically ambiguous situations. By doing so, they found they could tolerate the uncertainty and regained self-confidence. Behavior changes occurred as a result of implementing the strategies to cope with uncertainty.
Changes in attitude
“I realized that being incorrect or not knowing an answer was not a particularly bad thing; simply meant I was going to learn more that day. ... I stopped feeling guilty about not knowing everything and realized it was impossible”.
Being prepared
“Sometimes, the physician must make life or death decisions in a short amount of time. All these aspects of being a physician place large amounts of responsibility over our shoulders. We must prepare enough so that when the time comes we can shoulder that load, for the patients/nurses/techs look to us for the answers. Understanding and upholding that responsibility by being prepared is an important concept to being a physician.”
Working in a team
“I have learned a lot about medicine, but more importantly I have learned that I will never know everything. This is both a motivator to keep learning from every patient encounter and a great relief since it is okay not to be the expert on every topic. That’s because medicine is a team sport. I have found that knowing the right resources and people can be more effective than memorization. This is also a great approach to life as networking can often get you farther than individual effort alone.”
“it is impossible to be all knowing when it comes to medicine, and much of being a physician is working as a team and figuring it out.”
Patient-centered approach
“My thought processes have shifted from a self-centered approach, for lack of a better word, to a patient centered approach that uses me and my knowledge as a voice for that patient’s education.”
Use of time
“being well prepared for the medicine I was going to see in clinic the next day was more important than adding those 10 extra practice questions.”
Studying
My “new approach” to learning is less of a new strategy and more of a new attitude. It is not just that I read every day now, but that I read with a hunger for knowledge. For example, when I read about asthma, I used to ask myself, “On a test, what do they ask about asthma and what are the right answers?” Now I ask, “How would I distinguish an asthma exacerbation from pneumonia or foreign body aspiration?”