J.S. Ilgen is associate professor, Department of Emergency Medicine, and associate director, Center for Leadership and Innovation in Medical Education, University of Washington, Seattle, Washington; ORCID: https://orcid.org/0000-0003-4590-6570.
J.L. Bowen is professor, Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington; ORCID: https://orcid.org/0000-0001-6914-0413.
Acad Med. 2020 Nov;95(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 59th Annual Research in Medical Education Presentations):S67-S72. doi: 10.1097/ACM.0000000000003634.
Clinical educators often raise concerns that learners are not comfortable with uncertainty in clinical work, yet existing literature provides little insight into practicing clinicians' experiences of comfort when navigating the complex, ill-defined problems pervasive in practice. Exploring clinicians' comfort as they identify and manage uncertainty in practice could help us better support learners through their discomfort.
Between December 2018 and April 2019, the authors employed a constructivist grounded theory approach to explore experiences of uncertainty in emergency medicine faculty. The authors used a critical incident technique to elicit narratives about decision making immediately following participants' clinical shifts, exploring how they experienced uncertainty and made real-time judgments regarding their comfort to manage a given problem. Two investigators analyzed the transcripts, coding data line-by-line using constant comparative analysis to organize narratives into focused codes. These codes informed the development of conceptual categories that formed a framework for understanding comfort with uncertainty.
Participants identified multiple forms of uncertainty, organized around their understanding of the problems they were facing and the potential actions they could take. When discussing their comfort in these situations, they described a fluid, actively negotiated state. This state was informed by their efforts to project forward and imagine how a problem might evolve, with boundary conditions signaling the borders of their expertise. It was also informed by ongoing monitoring activities pertaining to patients, their own metacognitions, and their environment.
The authors' findings offer nuances to current notions of comfort with uncertainty. Uncertainty involved clinical, environmental, and social aspects, and comfort dynamically evolved through iterative cycles of forward planning and monitoring.
临床教育者经常担心学习者不适应临床工作中的不确定性，但现有文献对临床医生在处理实践中普遍存在的复杂、定义不明确的问题时感到舒适的经验几乎没有深入了解。探索临床医生在实践中识别和管理不确定性时的舒适感，可以帮助我们更好地支持学习者克服不适。
在 2018 年 12 月至 2019 年 4 月期间，作者采用建构主义扎根理论方法探索急诊医学教师的不确定性体验。作者使用关键事件技术引出参与者临床轮班后立即做出决策的叙述，探讨他们如何体验不确定性，并实时判断自己管理特定问题的舒适度。两名调查员分析了转录本，使用持续比较分析逐行对数据进行编码，将叙述组织成重点代码。这些代码为理解不确定性舒适度提供了概念类别。
参与者确定了多种形式的不确定性，这些不确定性围绕着他们对所面临问题的理解以及他们可以采取的潜在行动展开。当讨论他们在这些情况下的舒适度时，他们描述了一种流动的、积极协商的状态。这种状态受到他们向前预测和想象问题如何演变的努力的影响，边界条件标志着他们专业知识的边界。它还受到与患者、自身元认知和环境相关的持续监测活动的影响。
作者的发现为不确定性舒适度的现有概念提供了细微差别。不确定性涉及临床、环境和社会方面，舒适度通过前瞻性规划和监测的迭代循环动态演变。
