Background: Uncertainty, defined as the “subjective perception of ignorance”(1), is an inescapable and familiar reality to those who practice hospital medicine. An inability to tolerate uncertainty is associated with burnout, anxiety, depression, and inappropriate use of resources (2). Learning more about how hospitalists experience and manage uncertainty will aid us in promoting high-value care by optimizing clinical decision-making strategies and encouraging appropriate resource use. Furthermore, understanding more about the hospitalists’ experience of uncertainty will inform strategies to mitigate burnout and other mental health consequences associated with uncertainty intolerance.
Methods: We used constructivist grounded theory to develop a model of how hospitalists experience and manage uncertainty. Data was gathered through semi-structured interviews with hospitalist attending physicians at an academic medical center. Interviews were conducted by a hospital medicine physician, recorded on Teams, and carried out longitudinally over each participant’s 7-day work week. We used a semi-structured interview guide to discuss one or more challenging cases with each participant. Analysis of transcripts occurred concurrently with data collection, using inductive reasoning sensitized by existing research on uncertainty in other clinical contexts (1,3-7).
Results: We have identified that hospitalists are uncertain not only about the diagnosis/management of various medical conditions but also about their own abilities, how to discharge patients, what the patient is thinking, and how to manage disagreement among the care team. While they describe frustration, anxiety, and helplessness in the face of uncertainty, hospitalists also describe a sense of feeling “stuck”. A variety of uncertainty management strategies have been illustrated. First, hospitalists employ various communication strategies in the face of uncertainty, one of which is documentation. Hospitalists also manage uncertainty by triaging the urgency of illness, adopting a heightened sense of awareness, setting boundary conditions, and forward planning. Hospitalists describe conducting therapeutic trials and developing surrogate goals. Finally, hospitalists explain the work they do in anticipation of uncertainty. This includes reading notes before going onto service and starting notes prior to starting service.
Conclusions: We aimed to learn more about how hospitalists experience and manage uncertainty to improve hospitalist emotional well-being and promote high-value care. Several themes stand out as most unique and potentially translatable to this goal. First is the use of surrogate goals employed by the hospitalists. The development of, and refocusing upon, goals other than the elimination of uncertainty gives the hospitalist permission to move forward with care despite remaining uncertain thereby improving uncertainty tolerance. Another strategy of interest is the setting of boundary conditions. The hospitalists describe putting in place a threshold at which point their watchful waiting will end and they will take action. This strategy promotes thoughtful contingency planning and resource use. Finally, with the strategies employed by hospitalists in anticipation of uncertainty in mind, we may consider restructuring our work week to give hospitalists time in advance of their work week to prepare knowing this may too promote uncertainty tolerance.