A diagnosis is a judgement characterized by uncertainty and probabilistic reasoning: it is seldom definitive at the initial point of care.

Gurpreet Dhaliwal, MD

Great clinical teachers recognize that uncertainty is an inherent aspect of making a clinical diagnosis, particularly when symptoms are nonspecific or change over time. In a recent review, diagnostic uncertainty was defined as a “subjective perception of an inability to provide an accurate explanation of the patient’s health problem.”1  Physician discomfort with uncertainty has been associated with burnout, over-testing, increased health care expenditures, and diagnostic errors.2,3  Over time, skilled clinicians become increasingly comfortable with accepting and navigating uncertainty, in part because they treat diagnoses as provisional hypotheses or “working diagnoses” instead of definitive diagnoses.4,5  They recognize that clinical reasoning in the face of uncertainty requires a thought process in which several potential diagnoses are weighed as new information is considered, evaluated, and contextualized.6 

Learners commonly struggle when they encounter uncertainty.7  Several reasons may contribute to the difficulty experienced by learners, including limited situation-specific knowledge, fewer relevant previous clinical experiences, lack of formal curricula to address uncertainty, testing strategies that highlight only a single best answer, discomfort sharing uncertainty for fear it will be perceived as weakness or will influence their evaluations,8  and lack of role models who exemplify approaches for addressing uncertainty.3 

The ability to accept uncertainty is recognized as a skill that all pediatric residents must demonstrate during their training,9  yet there are few interventions to prepare medical students and residents to deal with uncertainty.8,10  Given the harms of discomfort with uncertainty (eg, burnout and over-testing), learning to recognize and process uncertainty is crucial not only for students’ own growth but also for the health of their future patients.

Learners may enter clerkships with a notion that diagnoses are always clear, and many believe that when a certain degree of clinical competence has been obtained (such as completing residency), uncertainty will go away. It is therefore crucial that educators normalize uncertainty, when appropriate, in the same way they need to normalize making mistakes.11  As new pieces of history, examination findings, or diagnostic results emerge, new uncertainties will also emerge. Expert clinical teachers can encourage a growth mindset12  and can role model habits of lifelong learning because even seasoned clinicians are aware that years of clinical experience still does not “protect against the challenges of uncertainty.”13  As part of orientation, great clinical teachers can talk to learners about the ubiquity of uncertainty in medicine. Using scripts (such as, “Making a diagnosis is sometimes challenging, and often times there are several possibilities that we may need to consider”) can help open a dialogue about uncertainty with learners up front.

Once the stage is set that discussing uncertainty is not only acceptable but encouraged, the learner now can be taught how to recognize and respond appropriately to this uncertainty. We have adapted a previously described teaching model, the one-minute preceptor, which can serve as a framework for clinical teachers to help learners recognize and respond to uncertainty. The one-minute uncertainty preceptor is outlined in the following section.

TABLE 1

The One-Minute Uncertainty Preceptor

StepDescriptionExample Scripts
Commitment and certainty “What do you think is going on?” 
  “How certain are you?” 
Probe “What are the aspects of the case that make you feel more or less certain?” 
  “What else could it be?” 
  “How are you feeling about this case right now?” 
  “What other pieces of information would you want to gather?” 
  “How are you going to monitor whether you made the right decision?” 
  “How are you going to monitor this problem as it progresses?” 
  “What cues might signal that you are veering into dangerous territory when you need help?” 
  “Whom could you call for help?” 
Teach and role model “This is how I’m feeling about the case right now.” 
  “This is how I weigh the pros and cons in a situation like this.” 
  “One way we can tell if we made the right decision is ____.” 
  “I’m feeling a little uneasy right now because___.” 
  “I’m feeling uncertain of what to do for this patient.” 
  “I can’t explain why this patient is having bloody stools, but my working hypothesis is___.” 
  “You know what my ‘unknowns’ are for this case…? Given that, here is my action plan.” 
Reinforce what was done well What the learner did well 
Correct mistakes What the learner can do better 
StepDescriptionExample Scripts
Commitment and certainty “What do you think is going on?” 
  “How certain are you?” 
Probe “What are the aspects of the case that make you feel more or less certain?” 
  “What else could it be?” 
  “How are you feeling about this case right now?” 
  “What other pieces of information would you want to gather?” 
  “How are you going to monitor whether you made the right decision?” 
  “How are you going to monitor this problem as it progresses?” 
  “What cues might signal that you are veering into dangerous territory when you need help?” 
  “Whom could you call for help?” 
Teach and role model “This is how I’m feeling about the case right now.” 
  “This is how I weigh the pros and cons in a situation like this.” 
  “One way we can tell if we made the right decision is ____.” 
  “I’m feeling a little uneasy right now because___.” 
  “I’m feeling uncertain of what to do for this patient.” 
  “I can’t explain why this patient is having bloody stools, but my working hypothesis is___.” 
  “You know what my ‘unknowns’ are for this case…? Given that, here is my action plan.” 
Reinforce what was done well What the learner did well 
Correct mistakes What the learner can do better 

First described by Neher et al,14  the one-minute preceptor is a well-established strategy for clinical teaching that has been shown to improve skills in the domains of medical knowledge and clinical reasoning. The model includes 5 steps: (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done well, and (5) correct mistakes. With a few simple modifications to steps 1, 2, and 3, the one-minute preceptor can be adapted to the one-minute uncertainty preceptor to help facilitate targeted conversations regarding uncertainty (Table 1).

This first step allows the educator to identify potential uncertainty in the learner. The traditional one-minute preceptor model requires the learner to commit to a diagnosis or management option. The one-minute uncertainty preceptor incorporates this approach with an additional follow-up question: “How certain are you?” This simple question may help to initiate the conversation between the learner and the educator regarding the relative certainty surrounding a case. Although not all learners will realize they are uncertain or be willing to admit they are uncertain, this opening question can provide an invitation to begin this discussion.

This step promotes self-reflection and remains similar to the traditional model but with a specific focus on reasons for the learner’s uncertainty. Uncertainty provides an excellent opportunity for reflection. Studies suggest that clinicians who engage in self-reflection can reduce the negative impacts of uncertainty on patient care.15  In this step, the educator asks the learner to explain the aspects of the case that make them more or less certain so that the educator can facilitate learning focused on uncertainty.

To do this, educators can have learners identify the most disconcerting or the key area(s) that are contributing to their uncertainty. The educator may also ask the learners to discuss other potential diagnoses, how they can mitigate some of the uncertainty, and how they may know if they made the right decision as time passes.

Finally, the educator can role model an approach to handling uncertainty. In the traditional model, this step allows the educator to highlight 2 to 3 key teaching points based on the case. To modify this step for uncertainty, rather than teach knowledge-based concepts, the educator can address specific aspects of the case that are leading to uncertainty. For example, the educator can call out reasons why one may be uncertain in a situation such as the current case, ways in which one may mitigate that uncertainty, and ways in which one would know if the decision made for a patient was the most appropriate. This step provides an opportunity for the educator to share how he or she leverages discomfort to inform clinical reasoning around an ill-defined problem.

These steps (reinforce what was done well and correct mistakes) remain unchanged in the one-minute uncertainty preceptor model.

Great clinical teachers can use the one-minute uncertainty preceptor to guide their one-on-one interactions with learners. Equally important, however, is having the educator facilitate an environment that accepts and even embraces diagnostic uncertainty. In this way, the presence of uncertainty is not a reflection of a learner’s failure or a demonstration of weakness but rather a welcomed part of clinical reasoning that spurs curiosity, learning, and growth.

Dr Beck conceptualized and designed the manuscript, wrote the initial version, and reviewed and revised the manuscript; Dr Long helped with the conceptualization and design of the manuscript and reviewed and revised the manuscript; Dr Ryan helped with the conceptualization and design of the manuscript, was the primary author of the table, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.