“One step away from ‘you don't know what you're doing’”: A qualitative study exploring perspectives of uncertainty among residents and early career clinicians

Abstract

Objectives The inevitability of uncertainty in clinical practice is reflected within current competency frameworks, which emphasize that all trainees must learn to recognize and respond to uncertainty. Yet it remains unclear how trainees can learn this skill when the dominant ethos of medical training equates competence with certainty. Thus, we sought to explore how early career clinicians (ECC) and residents understand the significance of clinical uncertainty and its relationship with competence. Methods Using constructivist grounded theory, we conducted semi-structured interviews with 13 residents and 11 ECC (n=24), from ten different specialties. Iterative data collection and analysis directed constant comparison and theoretical sampling to sufficiency. Results Our analysis developed three main dimensions of uncertainty: (1) Trajectories of uncertainty, (2) Performances of (un)certainty and (3) Pedagogies of uncertainty. Trajectories captured the dynamic, non-linear relationship between uncertainty and experience. Performances highlighted how declarations of uncertainty are often constrained by gendered social norms and other implicit biases. Pedagogies identified the predominantly informal curriculum that shapes how our participants made inward and outward judgements of competence in light of uncertainty. Conclusions Our analysis reveals a complexity that is not captured by existing competency frameworks, which position “managing uncertainty” as a skill that is straightforwardly mastered during training. Rather, our participants described a non-linear evolution in how they both managed and understood the significance of uncertainty in their clinical practice. A lack of intentional, structured curriculum enables implicit biases about uncertainty and its relationship with competence to persist.