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.

中文翻译：

---

不确定性的隐式表达——经验派生框架的建议


不确定性存在于医生的日常工作中，几乎在每个临床环境中，并且也存在于临床推理过程中。医生在交接期间传达思维过程中的不确定性的方式对于患者安全至关重要，因为不确定性对参与患者护理的个人有不同的影响。处理不确定性和表达不确定性是医学生专业认同发展的重要过程。许多研究关注如何处理不确定性以及不确定性是否被明确表达。几乎没有任何关于不确定性的隐式表达的研究。因此，我们研究了扮演新住院医师角色的医学生在模拟交接期间隐式表达不确定性的方式。 67 名高级本科医学生参加了模拟的第一天住院医师培训，包括咨询时间、具有跨专业互动的患者管理阶段以及患者交接。我们逐字转录视频交接，并使用扎根理论方法提取有关不确定性表达的语言。表达患者相关信息的文本序列在语言方面进行了分析和编码，这隐式地修改了关于增加或减少不确定性的简单信息。概念和类别被开发和讨论，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式表达框架，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子类别“行动”或“结果”相关。在每个类别和子类别中，我们发现了一个表达式子集，它们隐式地减弱或增强了简单信息，从而分别增加了不确定性或确定性。隐式削弱简单信息的语言属于有问题的、不完整的、可改变的和不可靠的类别，而我们可以将隐式强化者归因于自信的、充分的、重点突出的和可靠的类别。我们提出的不确定性隐式表达框架可能有助于提高临床推理过程中不确定性表达的意识，并为教学过程中不确定性的显性化提供支持。这可能会导致医疗保健专业人员之间的沟通过程更加透明，并最终提高患者的安全。