From first-year residents to experienced senior faculty, all physicians regularly encounter diagnostic uncertainty. As the medical complexity of hospitalized patients continues to increase, it seems likely that instances of diagnostic uncertainty in the inpatient setting will follow suit. For many resident trainees, navigating uncertainty is intertwined with feelings of anxiety, self-doubt, and fear of being seen as incompetent. Yet, patient safety and the timely delivery of high-value care are often dependent upon effective communication between residents and attending physicians during situations of uncertainty. Prior research has investigated the communication of uncertainty with patients, but far less attention has been devoted to understanding this phenomenon within the resident-attending dyad. In their mixed-methods survey study, entitled “Residents’ Communication with Attendings About Uncertainty: A Single-Site Longitudinal Survey,” Kerr et al. sought to elucidate residents’ perceptions of communicating uncertainty with their attending physicians, residents’ goals during that communication, and challenges that arise during the process (10.1542/hpeds.2024-007777).
They recruited two consecutive cohorts of incoming interns (100 total) from the pediatrics and internal medicine-pediatrics residency programs and surveyed those participants once per academic year over three years. Surveys included both Likert-scale items and open-ended prompts. Hierarchical linear modeling was used to assess changes over time while accounting for the clustered data “phases” of academic years.
Analysis of Likert-scale data revealed that residents’ communication efficacy (e.g., their self-reported confidence in communicating about uncertainty) and their target efficacy (e.g., perceptions of the attending physicians’ ability and willingness to discuss uncertainty) both significantly increased over time. These results were consistent with prior research that showed residents’ comfort with uncertainty increases throughout training. Participants’ sex, medical degree, and class cohort were not associated with significant changes in communication efficacy nor target efficacy.
The authors coded over 550 open-ended responses into a priori themes of task, identity, and relational goals and challenges. These qualitative results revealed that, despite residents’ overall improvements in communication and target efficacies over time, there are a multitude of competing goals and challenges that persist. Many residents expressed difficulty in conveying their uncertainty due to competing identity goals (such as wanting to appear knowledgeable and competent) and competing relational goals (such as wanting to maintain the trust and respect of attending physicians). The authors note that communication challenges described by residents “overwhelmingly involved identity goals” and that the most common themes were centered on being perceived as knowledgeable, competent, and confident.
Overall, these results suggest that our medical education programs should be providing focused training on ways to effectively communicate about uncertainty. However, effective communication regarding diagnostic uncertainty is a two-way street; with this in mind, I agree with the authors’ suggestion that communication training should target both trainees and attending physicians. Rather than assume that all attending physicians possess expertise in coaching residents through moments of uncertainty, we should strive to include such communication training in faculty development. By recognizing and addressing the communication barriers that often exist within our hierarchical training system, we can enable residents to achieve more of the goals that are integral to their development as effective clinicians.
