Hamui-Sutton Alicia, Vives-Varela Tania, Gutiérrez-Barreto Samuel, Leenen Iwin, Sánchez-Mendiola Melchor
Faculty of Medicine, Universidad Nacional Autónoma de México, Mexico City, Mexico.
Unidad de Posgrado, División de Estudios de Posgrado, Ciudad Universitaria Mexico, Edificio G, 2 piso, oficina G226, C.P. 04510, Coyoacán, D.F., Mexico City, Mexico.
BMC Med Educ. 2015 Nov 4;15:198. doi: 10.1186/s12909-015-0459-2.
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.
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.
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.
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.
医学不确定性与医生的执业行为有着内在联系，通常会影响其患者护理、工作满意度、继续教育以及医疗保健系统的总体目标。本文识别了一些扩展现有类型的新型不确定性，并研究了应对这些不确定性的背景和策略。
我们开展了一项混合方法研究，包括定性和定量两个阶段。对于定性研究，128名住院医师报告了他们临床实践中的关键事件，并描述了他们如何应对当时的不确定性。对每个关键事件进行分析，共保留了45个最突出的情况。在定量阶段，另一组120名住院医师针对这些情况中的每一种表明他们是否曾参与所述情况，如果参与了，他们采用了哪种应对策略。分析考察了情况特征与应对策略之间的关系。
从定性研究中得出了一种新的不确定性类型，区分了技术、概念、沟通、系统和伦理不确定性。定量分析表明，无论不确定性类型如何，关键事件最常通过咨询上级医师来解决（总体占49%），这突出了医院等级关系的重要性。本研究获得的见解被整合到一个住院医师医学不确定性综合模型中，该模型结合了不确定性的类型和感知水平、应对不确定性所采用的策略以及情境因素，如当时在场的人员。该模型考虑了在患者、医疗系统和医生个人三个层面上的最终解决情况。
本研究深入了解了住院医师在不同类型的不确定性下如何做出决策，考虑了互动发生的背景以及用于解决事件的策略。这些见解可能会指导制定组织政策，以减少住院医师临床培训期间的不确定性和压力。
