Exploring the presence and roles of humility when experiencing situations of uncertainty

Abstract

Background

Uncertainty is a pervasive challenge in clinical practice. Whereas the importance of humility in navigating uncertainty has been discussed, empirical research on how humility is practiced or expressed (i.e., humility in action) is lacking. This study examines humility's presence and role in physicians' uncertainty experiences during the COVID‐19 pandemic. The objectives were to determine if and how humility presented in physicians' reflections on uncertain situations during the height of the COVID‐19 pandemic and to explore potential roles of humility in managing uncertainty.

Methods

After intercoder reliability was established, four members of the author team utilized qualitative data analysis software to conduct a secondary analysis of critical incident interviews with 12 physicians (seven ED and five ICU physicians) about experiences with uncertainty while caring for COVID‐19 patients. To identify if humility was present in situations of uncertainty, the authors deductively coded transcripts for key elements of humility based on previously published conceptualizations by Tangney (2000) and Gruppen (2015). Additionally, the authors examined code co‐occurrence to identify clusters of humility and conducted a thematic analysis to uncover potential roles of humility and what humility “looks like” in clinical situations.

Results

Aspects of humility were frequently present in physicians' narratives. Acknowledgment of shortcomings was most common. Acceptance of limitations, openness, and perspective‐taking frequently co‐occurred. Two key themes emerged: humility allowed physicians to trust their training despite uncertainty and enabled pivoting and adapting to new information.

Conclusions

Findings suggest that humility facilitates managing uncertainty by promoting trust in abilities and enabling flexibility and openness. Formal training in humility may better prepare clinicians for uncertainty. Further research should explore nuances of humility across clinical situations and types of uncertainty.

INTRODUCTION

Uncertainty is a fundamental aspect of clinical practice, woven intricately into the fabric of medical decision making and patient care. ¹ According to Tonelli and Upshur, ² “Uncertainty describes situations where knowledge or understanding is insufficient to allow for confident clinical decision making.” In the complex terrain of health care, where symptoms can be enigmatic and conditions multifaceted, clinicians often confront a myriad of potential diagnoses and treatment paths, each potentially shadowed by a veil of uncertainty. Moreover, the intricate interplay of patient‐specific variables, the inherent unpredictability of disease progression, and the limits of current medical knowledge collectively contribute to a state of uncertainty in the clinical setting. ³ While this can engender apprehension, it also underscores the importance of critical thinking, evidence‐based reasoning, and the art of balancing risks, benefits, and patient preferences, fostering an environment where humility, adaptability, and continuous learning become indispensable virtues for providing optimal patient‐centered care. ⁴

Although there have been recent calls for the exploration of and engagement with humility in clinical care, specifically regarding uncertainty, ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ these mainly consist of editorials and commentaries that emphasize the value of humility, and its tenets thereof, such as open‐mindedness, acceptance of limitations in knowledge and abilities, and realistic awareness of achievements, shortcomings, and fallibility. While this previous literature sheds light on humility's potential benefit, minimal empirical research has been conducted to better understand how humility is practiced or expressed (i.e., humility in action) and the role(s) humility may play within situations of clinical uncertainty.

Humility is often defined as an accurate self‐assessment, acknowledging one's limitations and gaps in knowledge, an openness to new ideas, and transcending self‐focus to appreciate others’ contributions and one's place within the broader universe. ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ Although scholars have highlighted the lingering conceptual dissonance regarding humility, ¹⁹ humility is generally considered a socially valuable and positive attribute that is not a sign of weakness or self‐abasement but rather reflects exceptional security, self‐accuracy, and confidence. ¹⁴

Empirically exploring the presence and role(s) of humility in situations of uncertainty within health care delivery is of paramount importance due to the intricate nature of medical practice and its potential consequences on clinical decision making, patient outcomes, and practitioner well‐being. In this study, we utilize care delivery–related situations of uncertainty during the COVID‐19 pandemic, as explained by the practitioners themselves, and identify the if and how regarding the potential presence of humility. In doing so, our goal is to provide a more thorough understanding of humility within health care delivery as well as the roles of humility in addressing challenging and uncertain clinical situations. By better understanding how humility may be practiced or expressed when navigating uncertainty in clinical practice, educators can specifically target skills development and training in formal curricula to prepare learners for the complexity of the clinical practice environment. This study aimed to explore how humility is demonstrated by physicians as they navigate real‐time learning amid the uncertainties inherent in clinical practice.

METHODS

The data utilized in this paper were collected during an institutional review board (IRB)‐approved study conducted in mid‐2021 (Thomas Jefferson University #21E.565) exploring how physicians working in the clinical learning environment experienced uncertainty in clinical practice during the height of the COVID‐19 pandemic. ⁵ The lead author's (BM) interest in previous literature connecting humility and uncertainty led to a dialogue with the original project team to further explore the interview data from the original project.

Data collection: sampling strategy and critical incident technique (CIT)

The purpose of the original study was to qualitatively explore how physicians working in high‐acuity clinical environments during the COVID‐19 pandemic experienced informal and incidental learning during times of heightened uncertainty during the early months of the pandemic. The interview protocol explicitly framed uncertainty within the context of high‐acuity care delivery during the height of the pandemic (i.e., patient care taking place in either the emergency department [ED] or the intensive care unit [ICU]) and defined uncertainty as the dynamic and subjective perception of not knowing what to think, feel, or do in the context of their clinical work. ²⁰ Participants were asked to identify and share a personal incident from the clinical environment that came to mind. Critical incidents were then explored over the course of the interview to uncover the learning that took place in the moment of these incidents.

Because the original study sought to understand how the uncertainty associated with the height of the COVID‐19 pandemic influenced learning in physicians working in extremely high‐stakes and complex clinical environments, the team intentionally recruited physicians who treated COVID‐positive patients in either the ED or the ICU at an urban, academic, tertiary care hospital in Philadelphia, Pennsylvania. Two authors of the original project (DP, UV) were faculty in these respective clinical departments and, therefore, familiar with the practice environment. While these two authors were affiliated with the data collection site, they represented individuals who were removed from direct decision‐making power structures within their respective departments. Their role in the original project was to facilitate purposive sampling from faculty without influencing responses.

Physician participants were identified through purposive convenience sampling. ²¹ Criteria for inclusion were that the individual worked as an attending physician treating patients with COVID‐19 in the ED or ICU at our institution from March to June 2020. To capture an array of clinical experiences across the physician life cycle, participants were chosen with varied accumulated years working clinically in the ED or ICU. Participants were enrolled through targeted emails describing the study and ensuring voluntary participation. Participants and their respective narratives were deidentified using an internally developed coding scheme. We identified and interviewed 12 physician participants, seven ED and five ICU physicians. Participants had a mean of 10 years of clinical experience in their respective field (range 4‐19 years). Five were female.

Data collection method: the CIT

The study consisted of a series of critical incident interviews, each 45 min long, with frontline ED and ICU physicians. Each interview was conducted virtually using Zoom software by two members of the original project team, which allowed for a clinician (i.e., DP, UV) and an adult learning expert (i.e., VJM, KEW, HL, GA) to be co‐interviewers. The CIT ²² was chosen as the data collection method since it is an approach that creates vivid depictions of the phenomena of interest as well as a window into the reasoning of the individual about the incident. ²² , ²³ , ²⁴ An interview protocol was developed by project team members with significant experience with the CIT (i.e., KEW, VJM, HL). The protocol for the original study was piloted with one ED and one ICU physician to optimize interview questions. The interview protocol was modified based on these pilot interviews, and the pilot interviews were included in the data set. Physician participants were asked to describe a key incident in their daily clinical work during the COVID‐19 pandemic when they were faced with a significant degree of uncertainty. Interviews were transcribed for analysis using Sonix software. Each recording ranged from 60 to 75 min. Transcriptions of recordings yielded over 120 pages of data. These transcripts were then reviewed by members of the original study team for transcription accuracy. The study was approved by the IEB of Thomas Jefferson University (#21E.565).

Data analysis for humility‐specific study

Full interview transcripts were utilized for the analysis with the primary goal to examine the potential presence and roles of humility as they relate to practitioners’ recounting of situations of uncertainty. In turn, the broad conceptualization of humility provided by Tangney ¹⁵ and the conceptualization of humility specific to medicine and medical practice provided by Gruppen ¹⁸ were employed as sensitizing concepts in a deductive fashion to identify if, where, and to what extent humility was evident in the interviews

Specifically, the key elements of humility seem to include the: accurate assessment of one's abilities and achievements (not low self‐esteem, self‐deprecation), ability to acknowledge one's mistakes, imperfections, gaps in knowledge and limitations (often vis‐à‐vis a “higher power”), openness to new ideas, contradictory information, and advice, keeping of one's abilities and accomplishments—one's place in the world—in perspective (e.g., seeing oneself as just one person in the larger scheme of things), relatively low self‐focus, a “forgetting of the self,” while recognizing that one is but one part of the larger universe, appreciation of the value of all things, as well as the many different ways that people and things can contribute to our world. ¹⁵

Humility is a willingness to acknowledge the possibility that you are fallible and may be wrong, that you need guidance or help from others on occasion, that you can benefit from feedback, and that you need to make changes in your performance. ¹⁸

We created a codebook where we dissected and operationalized these two conceptualizations of humility into 12 related but distinct elements of humility (see Table 1). The goal of the first stage of the analysis was to establish intercoder reliability (ICR). In turn, working individually with the same three interview transcripts, members of the author team (BM, DP, UV, LR) employed the elements of the conceptualizations provided by Tangney and Gruppen (see above for full conceptualizations) in a deductive fashion as codes themselves, identifying phrases and statements that featured these terms directly. Relatedly, but a distinct aspect of this stage of analysis, team members also analyzed these three interviews in a more inductive and open manner, identifying data that resonated with and were reflective of the key elements of Tangney's and Gruppen‘s conceptualizations but did not use the exact terminology as expressed in the conceptualizations. The team then convened to discuss findings, providing explicit detail of why and how what they identified was evidential of the Tangney and/or Gruppen conceptualization and/or humility in a broader sense. Overall, team members identified similar results, but in situations of discrepancy (i.e., differences between coders), these particular findings were discussed among the analysis team to establish if these were reflective of humility. This team‐confirmation process was infrequent as there were no remarkable differences noted between team members’ coding outcomes in this initial exercise to establish ICR, and the two discrepancy situations were resolved via consensus of the analysis team.

TABLE 1.

Frequency of elements of humility (codes) identified in data overall and exemplary quotations.

Element of humility	Freq. of code overall/No. of transcripts occurred	Exemplary quotations
Acknowledgment of shortcomings (Tangney 15 )	81/12	“So we really knew nothing about what to do with the patients, what treatments, options we had, who can stay, who should go home. And it ended up being a very busy night with a lot of people who are covered positive. And I think I struggled with a lot that night, was figuring out who to send home and keep in the hospital, knowing that the hospital was going to be seen to be full of patients. And I was trying to send home who I could.” (1)
Self‐assessment of abilities and achievements (Tangney 15 )	62/12	“I try very hard sometimes to practice what I call metacognition. Thinking about that, I'm thinking, but particularly when I think about that in and diagnostic bias, like I think. So this is not a little bit off message but I guess it relates. But I have learned over the years about certain traps that I particularly may fall into, about rushing to a diagnosis, for example. So. I know that has been one where I translated into certain techniques I use to kind of set up some speed bumps, so I don't like to roll right down the hill to the wrong diagnosis.” (4)
Openness (ideas, advice, feedback) (Tangney 15 )	56/12	“Then you would see me like on the side, go grab one of my trusted colleagues like Dr. Paid, and I pulled them aside for a conversation. ‘What do you think? I don't know what to do here.’ You might even see me calling my friend in Boston who was like a few weeks ahead of us as far as the COVID outbreak went. ‘What are you doing there?’ I remember calling people at NYU because, again, they were about a month ahead of us or a few weeks ahead of us. ‘What's going on there? What are you doing? What are you referring these people back about? How do they do?’ So that I would say there is there's a lot of formal consultation. And then there's also this stuff I kind of that, you know, on the side.” (4)
Keeping in perspective (abilities/achievements) (Tangney 15 )	53/12	“This was one of those things where, you know, I'm used to having a young patient where I can do something to make a difference and actually. You know, actually improve their outcome. And this and other similar situations, I actually I had to learn to, you know, almost let go and say we're going to do the best we can. But I you know, it just may not be in the cards. And that was hard because even through medical school and residency and the first, what, half year of my life of being an attending. I you know, I hadn't quite internalized that lesson yet, it seems, and COVID really unfortunately made that and made it very clear that. You know, we may think we have all the answers, but sometimes it's just it's just not enough, even in a young, healthy patient.” (6)
Fallibility (Gruppen 18 )	46/9	“I mean, I wish I would have known. Yeah, I mean, in retrospect, his mortality was pretty high. So I think the forces scoring, you know, I think some of the risk categories that only come from cohorts of people, but I think that would be helpful. Right. Because if I would have known oh, it turns out actually he wasn't.” (5)
Concern for others (Gruppen 18 )	41/10	“I wish I had known to not push, but. I guess actively advised for or maintaining her oxygenation with high flow or bipap for as long as she could tolerate. Well, the family had time and I also wish I had known that. How to put her in touch with her family, how to show them pictures, how to have them communicate, because for me, part of the COVID experience that was the absolute worst was how to get patients and families connected, because that's just terrifying and watching them be terrified as awful.” (2)
Confidence (Gruppen 18 )	36/11	“I revert to what I know about regular patients. And if somebody has a positive time or I just scan them, because when the data is inconsistent and doesn't really guide you toward a clear conclusion, you just sit on what you know.” (7)
Need for help/guidance (Gruppen 18 )	34/10	“And then, of course, when something doesn't match your expectations and you feel like it's either a teaching moment or you just need some reassurance from your colleagues, I remember bringing this up with everybody that I came in contact with. I'm like, not going to believe what happened to me, whether it was the med student, the resident, the fellow attending, who I was working alongside, I don't remember who the individuals were, but I just remember wanting to sort of share the pain I wanted. I wanted everybody else to sort of acknowledge what a surprise this was. You never want to go through something like that in isolation.” (12)
Appreciation of others (Tangney 15 )	33/12	“I think the people in the room there was just a sense of camaraderie, the sense we're all going through the same thing and we're all as equally as uncertain about what this is and how it's going to respond and how it progresses and whether we are actually all at risk. So I felt like the people sort of with me on the ground were the ones I most got support from. And we sort of all just mutually trusted each other's judgment. I never felt like they were questioning me or I was questioning them. I think that was the best example of just how of teamwork that was successful.” (8)
Need to make changes in performance (Gruppen 18 )	15/5	“So there were constant conversations going on in a group within that I am part of within the department itself that was like, ‘OK, so how are we modifying our way this week based on what we've learned on what's been published the last week?’ So it was very rapid cycle adjustments of what our standard of care was based on, just new information. So it was a constant moving target. Which I think is applicable to this patient, right, because data was coming out of like, ‘OK, who do we have to worry about? Who don't we have to worry about? What are the markers? When can you safely send home the eighty seven year old with multifocal now one, can't you?’” (5)
Low Self‐Focus (Tangney 15 )	13/4	“…every time a patient says, ‘Oh, hey, you know, thank you so much, Dr. You did great for me’ and I and I actually tell them, it's not me. It's the nursing staff. Don't thank me. I barely had any contribution in your care. Its the nursing staff that, you know, took care of you and moved me along. So I mean, these are some things that I actually genuinely understand because, you know, in medicine nursing ratios, the only thing that's noted to have mortality benefit, right? For four ICU patients, the better the nursing ratio, the better the hospital mortality.” (9)
Benefit from feedback (Gruppen 18 )	10/5	“I mean, kind of the way I think about rounds in general, because I think it's pretty arrogant to think that, you know, my answer should be the best answer. But, you know, I think, you know, the nurse practitioners have such like a wealth of their own experiences. And if anything, we were like putting them more at risk because they were doing the procedures on these patients early on, you know, so they were spending more time in the rooms.” (8)

Once ICR had been communally established and accepted, the analysis team members (BM, LR, DP, UV) coded the remaining transcripts (nine) in the same fashion—each member coding all nine individually. The team reconvened when all data had been coded to review and confirm results and reaffirm ICR. As all analysis was conducted using Dedoose 9.0.17, ²⁵ we utilized the code application and code co‐occurrence analysis features within the program to showcase the frequency and “overlap” of each code within the data.

In the final stage of analysis, to further explore how humility may be practiced or expressed (i.e., humility in action), including the roles of humility within situations of uncertainty, the highest frequencies of code co‐occurrences (i.e., sections of data with the most overlap of elements of humility) were extracted and those particular data were analyzed through opencoding by the analysis team to identify potential common themes. Having identified the presence of humility in the earlier stages of the analysis, by now utilizing these “clusters of humility,” we were able to dissect connections between humility and uncertainty, specifically in the areas of the data where humility was identified as the most present—thereby further elucidating humility's roles in situations of uncertainty.

RESULTS

We consistently found key elements of humility featured in physicians’ reflections of uncertain clinical situations in our secondary analysis. Occurrences of the elements (i.e., how many times the key elements of humility were identified in each transcript) ranged from 14 to 93 times per transcript, with the average humility element occurrence being 40 times within a single transcript. Overall, the most frequently identified element of humility was acknowledgment of shortcomings, appearing in all 12 transcripts for a total of 81 times. The least frequently identified element of humility was benefit from feedback appearing in five transcripts for a total of 10 times. Table 1 presents each element of humility, the frequency with which that element was identified in the data overall (i.e., among all 12 of the transcripts; numerator), the number of transcripts in which the element was identified (denominator), and representative exemplary quotations.

We did find the presence of two or more key elements of humility within particular segments of the data, which is not surprising given the similarities between Tangney's and Gruppen's conceptualization of humility. Table 2 displays the co‐occurrence of codes, if and where the key elements of the conceptualizations were found to overlap within the physicians’ reflections of uncertainty situations, with exemplary quotations. As Table 2 shows, the most common co‐occurring elements of humility were: self‐assessment of abilities and achievements and acknowledgment of shortcomings (37), fallibility and acknowledgment of shortcomings (31), and keeping in perspective (abilities/accomplishments) and acknowledgment of shortcomings (28). Notably, acknowledgment of shortcomings co‐occurred with other elements of humility more often than any other element of humility (178).

TABLE 2.

Frequency of co‐occurrence of elements of humility (codes).

Element of humility	Acknowledgment of shortcomings	Self‐assessment of abilities and achievements	Keeping in perspective (abilities/achievements)	Fallibility	Openness (ideas, advice, feedback)	Need for help/guidance	Confidence	Concern for others	Appreciation of others	Need to make changes in performance	Benefit from feedback	Low self‐focus
Acknowledgment of shortcomings		37	28	31	15	13	16	16	6	9	3	4
Appreciation of others	6	6	4	1	21	15	3	3		3	4	1
Keeping in perspective (abilities/ achievements)	28	26		19	8	6	20	5	4	3	2	4
Low self‐focus	4	2	4	4	2	1	2	6	1	2	1
Openness (ideas, advice, feedback)	15	11	8	8		24	7	7	21	7	5	2
Benefit from feedback	3	2	2	3	5	3	2	4	4	3		1
confidence	16	19	20	12	7	6		4	3	5	2	2
Fallibility	31	20	19		8	6	12	8	1	7	3	4
Need for help/guidance	13	13	6	5	24		6	5	15	5	3	1
Need to make changes in performance	9	7	3	7	7	5	5	7	3		3	2
Self‐assessment of abilities and achievements	37		26	20	11	13	19	10	6	7	2	2
Concern for others	16	10	5	8	7	5	4		3	7	4	6
Total	178	153	125	118	115	97	96	75	67	58	32	29

We identified two prominent themes from the analysis of the clusters of humility (i.e., the data corresponding to the highest frequencies of code co‐occurrence). In situations of uncertainty, aspects of humility allow you to: (a) trust your training and (b) pivot and adapt.

Humility allows you to: trust your training

Participants noted that despite a lack of specific knowledge about COVID‐19 (i.e., heightened uncertainty), they had extensive clinical training and knowledge that they could draw upon in the early stages of the pandemic. Physicians showed confidence and trust in their training and experience (i.e., what they did know) while humbly accepting their limitations of that knowledge and related abilities. Both humility and confidence provided some level of calm and reassurance while allowing them to embrace a mindset of doing their best and accepting that sometimes their best might not be good enough.

When there is no evidence what we revert to is instinct‐based medicine. Like this is what feels like the right thing to do based on other things that I've seen and pattern recognition and heuristics. So that's what we end up falling back on when there's no good evidence to guide our decision. And sometimes we're wrong. You just have to try something and accept the fact that you're doing your best based on what you know and what you've learned and what you're an expert in. And it may not work. (7).

…we were also doing what we were trained to do, given a patient with these vital signs in this appearance without really knowing whether that treatment was the most effective in this particular condition since it was all so new. And so a lot of what we did was really on reflex. Within the emergency setting, I think we were much more trained to operate on reflex and our heuristics rather than algorithmic thinking. (6)

Humility allows you to: pivot and adapt

From analyzing the clusters of humility occurrence data, we also found that aspects of humility such as openness, perspective‐taking, and self‐awareness allowed participants to respond to the adversity nested within situations of uncertainty. They were willing and able to pivot and adapt when new information presented itself and/or when the patient's situation shifted.

I think it just reinforces the idea that you have to, you can't just focus and ignore the peripheral information that may not fit whatever narrative you've constructed in your head. Right? I mean, it's always about kind of pivoting on the fly and doing things and changing is necessary, and that's just kind of an example of an unexpected, “something unexpected that you needed to do.” (11)

… when I'm faced with the thing that I don't know anything about right, I'm trying to put things together because this patient has eight things wrong with them. How do they all fit in one process? I will take out a piece of paper, I'll turn over my sign out and I draw on it, and I try to explain. And as I'm trying to explain it to myself, I'm teaching the fellows, but essentially I'm teaching myself and thinking about the complex problem from various angles and it becomes a learning and sharing moment. (9)

The potential “zones” of uncertainty

Our open coding of the clusters of humility also provided possible insights into the nature of situations of uncertainty and how uncertainty may relate to confidence. Figure 1 presents a rudimentary illustration of these particular findings.

FIGURE 1.

Potential confidence/uncertainty “zones.”

The data suggest that, and as Figure 1 depicts, there may be an inverse relationship between experiencing uncertainty and level of confidence (in knowledge, ability, self, etc.). Figure 1 shows this relationship through a series of hypothetical zones: white zone—low uncertainty–high confidence; gray zone—medium uncertainty–medium confidence; and black zone—high uncertainty–low confidence. Whereas the white zone is fairly self‐explanatory, the black zone is where individuals may become incapacitated by the intensity of the experienced uncertainty, their confidence wanes and they may become overwhelmed and unraveled. For example, these participants stated experiencing the following during moments of high uncertainty and low confidence:

… you know what goes through your minds when you're in the middle of a shift and there's been a mismatch of either expectations or predicted outcomes, you, at least this is what I experience. I don't want to generalize, but I start to spin my wheels. And so when you're, when we're inevitably faced with uncertainty, but when we don't handle it in either an efficient or an effective way, I think it bleeds over into a lot of other patient outcomes and it sort of erodes your confidence in real time and it's tough to get back on track. When there is a marked deviation from your set of expectations, it starts to sort of undermine your clinical confidence if faced with similar situations in the future. (12)

Especially when I saw the chest x ray, I thought, oh shit, I don't know. Like, I'm pretty sure this is what it is but what if it isn't COVID? Should we do high flow? Like, I heard that intubating these patients might be worse for them. We're not supposed to give them fluid. I hope I'm not missing sepsis. I doubt it because look at that lung I had. But primarily, what would I take away from that? I was thinking how do I? How do I confidently but honestly convey to both the patient and family members what I think my plan for the patient should be without having good data to support that plan? And that feeling lasted for a long time, longer than I would have liked. With more than just that patient I should say. (2)

DISCUSSION

Our findings suggest that humility can be seen as a resource in addressing and managing situations of uncertainty and that certain facets of humility may be more proficient or operative in the management of these situations—such as accepting our shortcomings, realistic awareness of our abilities, and the willingness to listen to others and be open to new information. Furthermore, we found that in situations of uncertainty, humility enables individuals to trust their training as well as facilitates pivoting and adapting to new information.

These are qualities frequently celebrated within medicine and medical education ²⁶ , ²⁷ —yet their instruction is often regulated to implicit and informal means. Therefore, given these findings, as well as the frequent calls for fostering humility among the current and future health care workforce, ⁶ , ¹⁹ , ²⁸ , ²⁹ it is critical to explicitly provide training in the practice and cultivation of humility. This suggestion is echoed in the recent editorial‐ and commentary‐based calls for embracing humility when confronted with uncertainty. ⁷ , ¹⁰ , ¹¹ , ¹² Moreover, in their recent thematic analysis of rich entrustment decision literature, ten Cate and Chen ³⁰ show that clinical supervisors find humility to be a key trainee feature when making entrustment decisions—especially in situations of uncertainty.

Although there has been extensive literature outlining training for uncertainty, ² , ³¹ , ³² there is scant evidence of the existence of humility‐building programs nested within undergraduate‐ and graduate‐level medical education or professional development platforms. This may be because of the (a) conceptual dissonance associated with humility, (b) uncertainty regarding if/how humility can be taught, (c) minimal empirical research, and/or (d) the saturated nature of health professions curricula and clinical training resulting in minimal time, space, or prioritization to develop and administer humility‐building programming. However, new online humility training programs are emerging, moving beyond the brick‐and‐mortar classroom and tapping into the e‐learning realm. Arizona State University's Center for Advancing Interprofessional Practice, Education and Research (CAIPER) offers I‐TEAM By Design, the Interprofessional Training in Empathy, (Humility), Affect and Mindfulness, a fully animated, asynchronous training program aimed at educating health profession students and health professionals alike in core concepts of patient‐centered, team‐based health care delivery and enhancing interpersonal and interprofessional communication and connectivity through the building of empathy and humility “muscles.” Although aimed at a more general audience, the University of Oregon's Division of Equity and Inclusion provides online assessments and e‐learning modules in cultural humility designed to enhance learners’ levels of cultural and social awareness. Additionally, the University of California Berkeley's Center for Cultural Humility (Chum) offers a two‐day cultural humility training program (via in person and/or videoconferencing) for academics, clinicians, community organizations, businesses, and policymakers. Moving forward, future education and training focused on managing uncertainty should incorporate the cultivation and practice of the tenets of humility, particularly acknowledgment of shortcomings, self‐assessment of abilities and achievements, and openness (ideas, advice, feedback).

We were not surprised to find the high rate of co‐occurrence of aspects of humility given the conceptual overlap between the Tangney and Gruppen conceptualizations, and we utilized these “clusters” to spotlight the more prominent facets of humility that may be at play in situations of uncertainty. Future research, however, should explore and dissect the presence and role(s) of humility in other key situations of medical education and health care delivery. For example, because Gruppen's conceptualization of humility primarily focused on situations of feedback, there may be different facets of humility that are more prominent in those specific interactions.

Moreover, there are notable conceptual counterparts of the general humility concept nested within the uncertainty literature—such as epistemic humility, prognostic humility, and even intellectual humility. Schwab ³³ states that, “Epistemic humility is a characteristic of claims that accurately portray the quality of evidence for believing the claim to be an accurate one.” According to Fins, ³⁴ prognostic humility reflects understanding gaps in knowledge and communication of prognostic uncertainty. Ballantyne ³⁵ provides an overview of the intellectual humility concept, “… commonly thought to be a mindset, disposition, or personality trait that guides our reaction to evidence as we seek to pursue the truth and avoid error.” He goes on to state, “This mindset frees us up to seek out and evaluate evidence in such a way that we are less influenced by our own self‐oriented motives and more oriented toward reality.” Although not explicitly stated within the data in this study, the tenets of intellectual humility and, even to some extent, prognostic humility were evident in our results, while evidence for epistemic humility was less clear. Scholars interested in the relationship between uncertainty and humility could utilize these conceptual counterparts (and the facets therein) as codes themselves within uncertainty narratives to more fully explore their presence compared to the general humility concept.

Michalec et al. ¹⁹ , ³⁶ state that within health care delivery and health professions education specifically, there is a professional humility that reflects the consistent ability and willingness to: (a) evaluate, account for, and respond to the occupational status hierarchy within health professions and beyond; (b) understand the strengths and limitations of one's own profession; and (c) accept and acknowledge the qualities, skills, knowledge, and aptitudes of other health professions and health care team members, including patients and caregivers, in decision making and care delivery processes. Michalec et al. further suggest that professional humility extends the individual trait–level humility (as well as intellectual humility) to consider the organization‐level and profession‐specific aspects of care delivery and training. Notably, the tenets of professional humility were indeed evident within this study—especially in regard to the frequently identified facets of acknowledgment of shortcomings, openness to feedback, fallibility, and appreciation of others. Scholars are just scratching the surface of how professional humility lends to collaborative care delivery. This specific study suggests that professional humility may play a protective role in managing uncertainty.

Similarly, although we have showcased humility within situations of uncertainty, scholars have outlined the multifaceted nuances of the uncertainty concept itself. ³ , ⁵ , ³⁷ , ³⁸ , ³⁹ How humility interacts with and within the core dimensions of uncertainty (source, subjective nature, and responses) is still unknown. Additionally, given the conceptual relatedness between uncertainty and ambiguity, future research should examine if, why, and how humility interacts with ambiguity. Whereas with uncertainty, confidence in decision making is in question due to insufficient evidence or knowledge, ambiguity reflects situations when multiple choices seem equally plausible and appropriate. ² The how of humility may present differently when there is evidence for multiple possibilities compared to when there is little to no evidence to formulate any possibilities. Fox's ⁴⁰ , ⁴¹ classic sociologic explorations of medical students’ and practitioners’ tolerance for uncertainty and ambiguity do not examine humility specifically—therefore, future research could also utilize her and others’ models of ambiguity in reference to the practice and the presence of humility in clinical care. Additionally, future research should explore how humility may be present and/or exercised within the various socialization and professionalization processes and mechanisms that Fox refers to as medical students’ “training for uncertainty” ⁴⁰ as well as what Russel and colleagues ⁴² refer to as medical students “training for professional uncertainty.” In short, although it is evident that facets of humility operate in addressing situations of uncertainty, given the conceptual fog that surrounds both uncertainty and humility, it is essential for future research to clear the air and provide better visibility to these connections and roles.

Our proposed zones of uncertainty (in relation to confidence) are data driven but, given their novelty and the multifaceted nature of the uncertainty concept, require further empirical examination and testing in the clinical realm(s), yet these findings suggest that aspects of humility may play a protective role, particularly in the gray zone of uncertainty. Accepting what you do and do not know, being open to new information, being willing to pivot to respond to adversity, and recognizing your own fallibility may keep you from feeling paralyzed and trapped by uncertainty. Humility may allow practitioners to loosen their grip on their expectations and predictions, accept the lack of situational control, and sit (somewhat) comfortably in the gray zone of (un)certainty and then make decisions and move forward. In this sense, humility may calm or settle the doubts and questions accompanying uncertainty and tap into confidence (and/or other psychological resources) so that one does not fall off the deep end into the black zone. However, it is important to note that within this study, confidence was employed as an analytic code and was found not to be as prominent in the data as other facets of humility. In turn, the role of confidence as it relates to humility and uncertainty in the clinical realm may be an area for future research to more fully explore.

To our knowledge, our study is the first to explore the intersection of humility and heightened uncertainty within the clinical workplace, especially under the high‐stakes conditions of COVID‐19 patient care. By better uncovering how humility manifests and facilitates learning in moments of significant uncertainty, we offer a unique contribution to the medical education literature. Specifically, our findings reveal that humility empowers clinicians to trust their training and adapt to new information—crucial competencies in the face of unknowns. This empirical evidence firmly supports the integration of humility‐focused training into medical curricula, advocating for explicit instruction in recognizing one's limitations, embracing openness to novel perspectives, and having the critical ability to pivot in response to dynamic clinical scenarios. We propose the development of targeted educational interventions that prioritize these aspects of humility, designed to be embedded from the early stage of medical school through to continuing professional development. These interventions could be simulation‐based learning experiences, reflective practice sessions, and interprofessional education modules, all aimed at reinforcing humility as a core clinical skill. This approach not only addresses a significant gap in current medical training but also sets a clear agenda for future research across multiple sites with varied institutional cultures to evaluate the impact of humility training on clinician resilience, team dynamics, and patient outcomes across various medical specialties and clinical settings. By doing so, our study not only advances the theoretical discussion around humility in medical practice but also lays a practical foundation for enhancing the preparedness of health care professionals to navigate the complexities of clinical care with confidence and humility.

LIMITATIONS

Essential to comprehending our discoveries is the thorough examination of the constraints within our research, primarily related to how the study was conducted and the timing of our interviews. Our study utilized interviews from physicians solely from two specific departments within a single academic hospital, thereby creating a sampling bias. This bias arose due to the limitation of the original study's scope to just one hospital and the convenience sampling strategy adopted by two of our authors who were acquainted with the practice environments examined. Despite this familiarity potentially influencing participants to candidly share their experiences, the sampling technique and sample size limit the generalizability of our findings. Future work should explore the role of humility in situations of uncertainty within various clinical departments and among a multitude of specialties. This would mitigate the influence and bias of institutional culture and policies (e.g., management structure, attitudes of institutional leadership) on our findings.

Furthermore, the original interviews were conducted in the summer of 2021, approximately 15 to 18 months following the initial arrival of COVID‐19 patients at that hospital. The substantial temporal gap between critical incidents and the interviews might have contributed to a recall bias, affecting the accuracy of participants' recollections of the events.

However, this temporal distance also allowed for a deeper reflection and contemplation on their experiences, facilitating a more comprehensive analysis during the interviews. This allowed the physicians to engage in meaningful discussions and reflections, potentially providing insights that might not have been apparent in the immediate aftermath of the critical incidents. Similarly, in analyzing the interview data, aspects of two humility conceptualizations were utilized. Although comprehensive and frequently cited in previous literature, the tenets of humility nested within these conceptualizations may not be reflective of the entirety of the humility concept. We acknowledge that the original interviews were conducted from the lens of learning through uncertainty, while this paper described a focused analysis of humility. It is conceivable that our interview protocol may have excluded explicit questions surrounding humility. However, the fact that humility was observed in our data is in itself a significant observation, which we may not have observed otherwise.

CONCLUSIONS

Our study underscores the role humility plays in navigating the complexities and uncertainties inherent in clinical practice, particularly highlighted during the height of the COVID‐19 pandemic. Interviews with physicians revealed that humility, primarily characterized by an acknowledgment of limitations and an openness to new perspectives, is not only desirable, but essential when navigating uncertainty in clinical practice. Our findings highlight the potential value of integrating humility‐building experiences into formal medical training to adequately prepare trainees for the unpredictable landscape of health care delivery. Future research should delve deeper into the specific functions of humility across diverse clinical scenarios and examine the impact of humility training programs on clinician, team, and patient outcomes.

AUTHOR CONTRIBUTIONS

Study concept and design: Barret Michalec, Urvashi Vaid, Dimitrios Papanagnou, Henriette Lundgren, Victoria J. Marsick, Karen E. Watkins, Deborah Ziring. Acquisition of data: Urvashi Vaid, Dimitrios Papanagnou, Karen E. Watkins, Victoria J. Marsick, Henriette Lundgren. Analysis and interpretation of data: Barret Michalec, Urvashi Vaid, Dimitrios Papanagnou, Henriette Lundgren, Karen E. Watkins, Victoria J. Marsick, Leela Raj. Drafting of the manuscript: Barret Michalec, Urvashi Vaid, Deborah Ziring, Leela Raj, Henriette Lundgren, Karen E. Watkins, Victoria J. Marsick. Acquisition of funding: not applicable.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

The original study was approved by the institutional review board of Thomas Jefferson University (#21E.565).

Michalec B, Papanagnou D, Raj L, et al. Exploring the presence and roles of humility when experiencing situations of uncertainty. AEM Educ Train. 2025;9:e11055. doi: 10.1002/aet2.11055