Background: In hospital medicine, uncertainty [the subjective perception of ignorance(1)] is an inescapable challenge that impacts both patient care and physician well-being (2). There is a gap in our understanding of what hospital medicine physicians are uncertain about and how they manage their uncertainties. We aimed to learn more about how hospitalists experience and manage uncertainty in clinical practice.
Methods: We used thematic analysis to learn more about how hospitalists experience and manage uncertainty. A hospital medicine physician conducted semi-structured interviews with hospitalist attending physicians at an academic medical center. Interviews were recorded on Teams, and carried out during and after the hospitalist’s 7-day work week. We used a semi-structured interview guide to explore specific patient cases involving uncertainty, as well as participants’ general experiences of uncertainty. Concurrently, we analyzed transcripts using inductive reasoning sensitized by research on uncertainty in other clinical contexts (1,3-7,8).
Results: We interviewed 12 hospitalists (5 female and 7 male) with post-graduate experience ranging from 4-15 years. We identified three main themes from our data. First, the sources of uncertainty encountered by hospitalists were diverse, spanning patients’ illnesses (e.g., determining a diagnosis or treatment), communication dynamics (e.g., managing conflicting goals between patients and families), and care processes (e.g., navigating complex discharge planning). These uncertainties were often layered, evolving, and interconnected. Second, participants emphasized that managing uncertainty is both cognitively and emotionally taxing. Hospitalists have a finite bandwidth to handle uncertainty, which must also accommodate the other workload demands they face. The cumulative burden of addressing multiple uncertainties across patients, layered on top of these broader demands, can quickly deplete their capacity, reducing their ability to manage effectively. Third, hospitalists employed a range of strategies to manage uncertainty, including therapeutic trials, setting surrogate goals, consulting specialists to ‘offload’ uncertainty, and proactively reviewing patient cases before coming on service to anticipate challenges and conserve bandwidth. The choice of strategy was shaped by the urgency of the situation, the patient’s level of risk, and the hospitalist’s cognitive and emotional resources.
Conclusions: This study has implications for both clinical practice and future research. With our understanding of how cognitively and emotionally demanding uncertainty can be, we must reframe uncertainty as a part of the hospitalist practice and workload. By viewing uncertainty in this light, we will ensure hospitalists have the necessary time and resources to manage uncertainty and mitigate burnout. Furthermore, the results of this study open the doors to future research, specifically research aimed at learning more about the effectiveness of each of the uncertainty management strategies identified.