III. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
TUM Medical Education Center, School of Medicine, Technical University of Munich, Munich, Germany.
BMC Med Educ. 2020 Mar 20;20(1):83. doi: 10.1186/s12909-020-1990-3.
Uncertainty occurs in physicians' daily work in almost every clinical context and is also present in the clinical reasoning process. The way physicians communicate uncertainty in their thinking process during handoffs is crucial for patient safety because uncertainty has diverse effects on individuals involved in patient care. Dealing with uncertainty and expressing uncertainty are important processes in the development of professional identity of undergraduate medical students. Many studies focused on how to deal with uncertainty and whether uncertainty is explicitly expressed. Hardly any research has been done regarding implicit expression of uncertainty. Therefore, we studied the ways in which medical students in the role of beginning residents implicitly express uncertainty during simulated handoffs.
Sixty-seven advanced undergraduate medical students participated in a simulated first day of residency including a consultation hour, a patient management phase with interprofessional interaction, and a patient handoff. We transcribed the videographed handoffs verbatim and extracted language with respect to expression of uncertainty using a grounded theory approach. Text sequences expressing patient related information were analyzed and coded with respect to language aspects which implicitly modified plain information with respect to increasing or decreasing uncertainty. Concepts and categories were developed and discussed until saturation of all aspects was reached.
We discovered a framework of implicit expressions of uncertainty regarding diagnostic and treatment-related decisions within four categories: "Statement", "Assessment", "Consideration", and "Implication". Each category was related to either the subcategory "Actions" or "Results" within the diagnostic or therapeutic decisions. Within each category and subcategory, we found a subset of expressions, which implicitly attenuated or strengthened plain information thereby increasing uncertainty or certainty, respectively. Language that implicitly attenuated plain information belonged to the categories questionable, incomplete, alterable, and unreliable while we could ascribe implicit strengtheners to the categories assertive, adequate, focused, and reliable.
Our suggested framework of implicit expression of uncertainty may help to raise the awareness for expression of uncertainty in the clinical reasoning process and provide support for making uncertainty explicit in the teaching process. This may lead to more transparent communication processes among health care professionals and eventually to improved patient safety.
不确定性几乎存在于每个临床环境中，也是临床推理过程中的一部分。医生在交接班过程中表达思维过程中的不确定性的方式对患者安全至关重要，因为不确定性对参与患者护理的个体有多种影响。处理不确定性和表达不确定性是本科医学生专业身份发展的重要过程。许多研究都集中在如何处理不确定性以及不确定性是否明确表达上。几乎没有任何研究涉及不确定性的隐含表达。因此，我们研究了医学生在模拟交接班过程中作为初级住院医师如何隐含地表达不确定性。
67 名高级本科医学生参加了一项模拟住院医师第一天的培训，包括咨询时间、跨专业互动的患者管理阶段和患者交接班。我们逐字转录了视频记录的交接班内容，并使用扎根理论方法提取了表达不确定性的语言。分析了表达患者相关信息的文本序列，并根据语言方面进行了编码，这些语言方面根据增加或减少不确定性来修改简单信息。概念和类别得到了发展和讨论，直到所有方面都达到饱和。
我们发现了一个关于诊断和治疗相关决策的不确定性隐含表达框架，分为四个类别：“陈述”、“评估”、“考虑”和“暗示”。每个类别都与诊断或治疗决策中的“行动”或“结果”子类别有关。在每个类别和子类别中，我们发现了一组隐含的表达方式，这些表达方式分别减弱或增强了简单信息，从而增加或降低了不确定性。隐含地减弱简单信息的语言属于可疑、不完整、可改变和不可靠类别，而我们可以将隐含的增强器归因于断言、充分、集中和可靠类别。
我们提出的不确定性隐含表达框架可能有助于提高对临床推理过程中表达不确定性的认识，并为教学过程中使不确定性明确化提供支持。这可能会导致医疗保健专业人员之间更透明的沟通过程，并最终提高患者安全性。
