A typology of uncertainty derived from an analysis of critical incidents in medical residents: A mixed methods study

BMC Medical Education

Melchor Sánchez-Mendiola³  Iwin Leenen¹  Samuel Gutiérrez-Barreto³  Tania Vives-Varela³  Alicia Hamui-Sutton² 

[1]Instituto Nacional para la Evaluación de la Educación, Mexico City, Mexico

[2]Unidad de Posgrado, División de Estudios de Posgrado, Ciudad Universitaria Mexico, Edificio G, 2 piso, oficina G226, C.P. 04510, Coyoacán, Mexico City, D.F., Mexico

[3]Faculty of Medicine, Universidad Nacional Autónoma de México, Mexico City, Mexico

关键词: Uncertainty typology;    Clinical context;    Decision making;    Coping strategies;    Critical incidents;    Medical uncertainty;    Resident education;   

Others  :  1233364
DOI  :  10.1186/s12909-015-0459-2

 received in 2015-02-10, accepted in 2015-10-06,  发布年份 2015

【 摘 要 】

Background

Medical uncertainty is inherently related to the practice of the physician and generally affects his or her patient care, job satisfaction, continuing education, as well as the overall goals of the health care system. In this paper, some new types of uncertainty, which extend existing typologies, are identified and the contexts and strategies to deal with them are studied.

Methods

We carried out a mixed-methods study, consisting of a qualitative and a quantitative phase. For the qualitative study, 128 residents reported critical incidents in their clinical practice and described how they coped with the uncertainty in the situation. Each critical incident was analyzed and the most salient situations, 45 in total, were retained. In the quantitative phase, a distinct group of 120 medical residents indicated for each of these situations whether they have been involved in the described situations and, if so, which coping strategy they applied. The analysis examines the relation between characteristics of the situation and the coping strategies.

Results

From the qualitative study, a new typology of uncertainty was derived which distinguishes between technical, conceptual, communicational, systemic, and ethical uncertainty. The quantitative analysis showed that, independently of the type of uncertainty, critical incidents are most frequently resolved by consulting senior physicians (49 % overall), which underscores the importance of the hierarchical relationships in the hospital. The insights gained by this study are combined into an integrative model of uncertainty in medical residencies, which combines the type and perceived level of uncertainty, the strategies employed to deal with it, and context elements such as the actors present in the situation. The model considers the final resolution at each of three levels: the patient, the health system, and the physician’s personal level.

Conclusions

This study gives insight into how medical residents make decisions under different types of uncertainty, giving account of the context in which the interactions take place and of the strategies used to resolve the incidents. These insights may guide the development of organizational policies that reduce uncertainty and stress in residents during their clinical training.

【 授权许可】

   
2015 Hamui-Sutton et al.

【 图 表 】

Fig. 1.

【 参考文献 】

• [1]Luther VP, Grandall SJ. Ambiguity and uncertainty: Neglected elements of medical education curricula? Acad Med. 2011; 86:799-800.
• [2]Jarrillo E, Granados A, Chapela MC. Estudiantes de medicina, un estudio de caso. Argumentos. 2000; 35:45-58.
• [3]Norma Oficial Mexicana (NOM 234-SSA1-2003) Utilización de campos clínicos para ciclos clínicos e internado de pregrado. http://www. salud.gob.mx/unidades/cdi/nom/234ssa103.html webcite
• [4]Timmermans S, Angell A. Evidence-based medicine, clinical uncertainty, and learning to doctor. J Health Soc Behav. 2001; 42:342-59.
• [5]Ghosh BA. Dealing with medical uncertainty. Minn Med. 2004; 87(October 2004):1-8.
• [6]Sánchez M, Hernández M. Toma de decisiones en Medicina Incertidumbre y probabilidad. In: Informática Biomédica. Sánchez M, Martínez AI, editors. Elsevier, México; 2014: p.249-264.
• [7]Morin E. Seven complex lessons in education for the future. United Nations Educational, Scientific and Cultural Organization, Paris; 1999.
• [8]Light D. Uncertainty and control in professional training. J Health Soc Behav. 1979; 20:310-322.
• [9]Beresford EB. Uncertainty and the shaping of medical decisions. Hastings Cent Rep. 1991; 21:6-11.
• [10]Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. Qual Saf Health Care. 2008; 17:122-126.
• [11]Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making. 2011; 31:828-838.
• [12]Gerrity MS, Earp JAL, DeVellis R, Light D. Uncertainty and professional work perceptions of physicians in clinical practice. Am J Sociol. 1992; 97:1022-1051.
• [13]Allison JJ, Kiefe CI, Cook EF, Gerrity MS, Orav EJ, Centor R. The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO. Med Decis Making. 1995; 18:320-329.
• [14]Greco V, Roger D. Coping with uncertainty: the construction and validation of a new measure. Pers Individ Dif. 2001; 31:519-534.
• [15]Carleton RN, Norton MA, Asmundson GJ. Fearing the unknown: a short version of the Intolerance of Uncertainty Scale. J Anxiety Disord. 2007; 21:105-117.
• [16]Abreu LF, Infante CB. Medical education challenged by the learning society. Gac Med Mex. 2004; 140:381-390.
• [17]Siegel ER, Rapp BA, Lindberg DA. Evaluating the impact of MEDLINE using the Critical Incident Technique. Proc Annu Symp Comput Appl Med Care. 1991: 83–87.
• [18]Chell E, Pittaway L. A study of entrepreneurship in the restaurant and café industry: exploratory work using the critical incident technique as a methodology. Int J Hosp Manag. 1998; 17:23-32.
• [19]Soler C. Los constructos en las investigaciones pedagógicas: cuantificación y tratamiento estadístico. Atenas. 2013; 4:85-101.
• [20]Dornan T, Mann K, Scherpbier A, Spencer J. Learning and teaching in workplaces. In Medical Education Theory and Practice. 1st edition. Edited by Elsevier. 2011:193 – 210.
• [21]Hamui SL. Las narrativas del padecer: una ventana a la realidad social. Cuicuilco, 2011; 52:51–70. http://www.redalyc.org/pdf/351/35124304005.pdf Accessed 25 Jul 2014.
• [22]Nevalainen M, Kuikka L, Pitkäla K. Medical errors and uncertainty in primary healthcare: A comparative study of coping strategies among young and experienced GPs. Scand J Prim Health Care. 2014; 32:84-89.
• [23]Maguire P, Pitceathly C. Key communication skills and how to acquire them. Br Med J. 2002; 325:697.
• [24]Tyagi A, Garudkar S, Gagare A, Thopte A. Medical Uncertainty: Are we better off in era of evidence based medicine? Int Journal Med Res Health Sci. 2005; 4(1):208-213.
• [25]McCall T. The impact of long working hours on resident physicians. N Engl J Med. 1988; 318:775-778.
• [26]Deaconson TF, O’Hair DP, Levy MF, Lee M, Schueneman AL, Condon RE. Sleep deprivation and resident performance. JAMA. 1988; 260:1721-1727.
• [27]Hillhouse JJ, Adler CM, Walters DN. A simple model of stress, burnout and symptomatology in medical residents: a longitudinal study. Psychology, Health & Medicine. 2000; 5:63-73.
• [28]Glick S. The impeding crisis in internal medicine training programs. Am J Med. 1988; 84:929-932.
• [29]Badger LW, Chesebro MJ, Hartman JA. First year residency stress: sources and mediators. Fam Pract Res J. 1987; 7:104-13.
• [30]Lifshitz A. La teoría experiencial del aprendizaje. Aprender de la experiencia. Educación en las Residencias Médicas. Graue E, Sánchez M, Durante I, Rivero O, editors. Editores de textos mexicanos, México; 2010.
• [31]Ajzen I, Brown TC, Carvajal F. Explaining the discrepancy between intentions and actions: The case of hypothetical bias in contingent valuation. Pers Soc Psychol Bull. 2004; 30(9):1108-1121.
• [32]Kühberger A, Schulte-Mecklenbeck M, Perner J. Framing decision: Hypothetical and real. Organ Behav Hum Decis Process. 2002; 89:1162-1175.
• [33]Sheeran P. Intention-behavior relations: A conceptual and empirical overview. Eur Rev Soc Psychol 2002; 1–36.
• [34]Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: An introduction to theory and research. Addison-Wesley, Reading, MA; 1975.
• [35]Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991; 50:179-211.
• [36]Hamui SL, Vives VT, Gutiérrez BS, Castro RS, Lavalle MC, Sánchez MM. Cultura organizacional y clima: el aprendizaje situado en las residencias médicas. Inv Ed Med. 2014; 3(10):74-84.
• [37]Stake RE. Evaluación comprensiva y evaluación basada en estándares. Graó, Barcelona; 2006.
• [38]Han PK. Conceptual Methodological, and Ethical Problems in Communicating Uncertainty in Clinical Evidence. Med Care Res Rev. 2012; 70(1):145-365.