Implicit expression of uncertainty - suggestion of an empirically derived framework

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.