Tolerance of uncertainty
Supporting work of the Urgent and Emergency Care theme with their Managing Uncertainty in the Emergency Department project, Dr Luke Budworth has led on the design of this study testing the association between doctors’ tolerance of uncertainty and i) resource use, ii) patient management decisions and iii) patient outcomes. It could be beneficial to target uncertainty tolerance through a future behaviour change intervention, if these links are positively supported by research evidence.
Uncertainty is endemic in many aspects of healthcare. Patients present with an infinite combination of complaints, comorbidities, demographics, meaning it is difficult to not only determine the cause of their complaints, but also their prognosis and the best way to help them. As such, doctors and other health professionals must learn to make optimal decisions in an environment both high in uncertainty and with high stakes. Nowhere is this more relevant than in emergency medicine.
Research shows that an inability to tolerate uncertainty is associated with several negative outcomes for doctors - such as higher burnout, lower resilience, lower wellbeing, and higher psychological distress and stress. Further, uncertainty tolerance has been found to correlate with material outcomes such as resource use. For instance, GPs with higher tolerance uncertainty may order fewer diagnostic tests, meaning they use fewer vital NHS resources. Research also shows that more experience as a doctor leads to higher tolerance - meaning that, while clearly an enduring personality trait factor, the degree of tolerance is somewhat malleable.
Given the above, we believe that supporting emergency doctors in tolerating uncertainty may be not only beneficial for their own wellbeing, but may help reduce resource use, and thus benefit the NHS more widely. As such, the aim of our ‘TofU project’ was to find out whether there is a link between uncertainty tolerance and resource use in the ED context, and, for the first time, test the hypothesis that increased tolerance is not associated with worse patient outcomes.
Uncertainty tolerance (UT) was measured through a self-report questionnaire developed as part of this study but based on the Physician’s Reaction to Uncertainty scale (Gerrity et al. 1990; 1995). Items from other validated scales in this field were added in to measure components of uncertainty specified in Hillen et al.’s model of uncertainty tolerance, but missing from the Physician’s Reaction to Uncertainty scale. The survey was administered to doctors working within 5 sites.
The electronic hospital medical record of a sample of patients seen by those doctors in the proceeding 30 days were also reviewed, and key resource use (test/treatment ordering) and patient outcome variables (e.g. readmissions, mortality) extracted using a bespoke data extraction tool developed as part of this project. Modelling assessed the relationship between doctors' UT and resource use and patient outcomes.
Dr Luke Budworth also collaborated with Emily Parker, a PhD student from the Yorkshire and Humber PSTRC on this project. Emily’s PhD is also focused on tolerance of uncertainty with the aim of developing a tailored intervention to increase uncertainty tolerance: please click here for further information (https://yhpstrc.org/research-themes-partners/workforce-engagement-and-wellbeing/our-projects/risk-and-uncertainty/).
N=41 doctors were recruited and N=389 patient records were matched to these. The mean UT of doctors was 3.6 (measured on a 1-5 scale with higher scores indicative of higher UT), ranging from 2.6 to 4.8.
No significant associations were found between UT and resource use or patient outcomes. This study is, therefore, the first to provide evidence that UT may not be associated with significant patient harm. The novel UT scale demonstrated a good range and balance of scores and high internal consistency. UT was found to be significantly correlated with lower doctor burnout, indicating an area for future research.
We are keen to further test the UT measure. The measure is copyrighted and we welcome requests for its use to enable further testing. Please contact Dr Andria Hanbury: firstname.lastname@example.org.
Here is a link to a video of Dr Luke Budworth discussing the study and its findings: www.youtube.com/watch?v=HB-YtAJx8po