Uncertainty experienced by newly qualified doctors during the transition to internship

Abstract

Introduction

Uncertainty is an inherent feature of medical practice. Uncertainty Tolerance (UT) describes how individuals experience and respond to uncertainty, with lower UT associated with negative outcomes, including burnout. Periods of career transition can be particularly uncertain, but there is little research into newly qualified doctors' uncertain experiences during their transition to internship (TTI). Early career doctors have a high incidence of burnout; therefore, understanding how new doctors experience uncertainty could be valuable. We explored the sources of, responses to and moderators of uncertainty during the TTI to inform support of this group.

Methods

Engaging social constructionism, we conducted a cross‐sectional qualitative study with 13 intern doctors who graduated from a single Australian medical school during their TTI. Participants completed a semi‐structured interview within five months of commencing practice in 2021. Data were analysed using framework analysis, informed by the integrative UT model.

Results

Although participants described clinical uncertainty during the TTI (i.e. unknown aspects of patient care due to ambiguity, complexity or probability), dominant sources of uncertainty related to novel scenarios (e.g. tasks and responsibilities experienced for the first time) and their professional role (e.g. boundaries and expectations). Participants described responding to uncertainty by asking for help from senior colleagues and reported feelings of stress. Key factors that moderated responses to uncertainty included support, time and perceived stakes.

Discussion

Our results suggest that educators, supervisors and employers should aim to reduce the extraneous uncertainties associated with the TTI. Approaches to achieve this could include orientation programmes that appropriately familiarise interns with workplace environments and systems, reducing role ambiguity by setting clear expectations and facilitating regular feedback, and creating psychologically safe working environments with adequate senior support. These approaches may allow newly qualified doctors the capacity to explore clinical uncertainties and develop their UT through methods such as critical reflection.

Short abstract

The transition from #medstudent to doctor is filled with uncertainties. @DrMollyDineen , @InsidOutAnatomy & @GeorgieofMelb describe how this group can be supported to develop uncertainty tolerance.

1. INTRODUCTION

Uncertainty is a pervasive feature of doctors' training and careers. How an individual experiences and responds to uncertainty is known as their uncertainty tolerance (UT). ¹ Health care professionals' UT is associated with the quality of health care delivered (e.g. diagnostic accuracy ² ) as well as their practising behaviours (e.g. number of referrals made ³ or tests ordered ⁴ ), and personal well‐being (e.g. burnout ⁵ , ⁶ ). ⁷ This understanding has led to many professional bodies including UT as an essential attribute for doctors, ⁸ , ⁹ and to investigators researching how this construct can be measured, ¹⁰ , ¹¹ , ¹² , ¹³ and developed. ¹⁴ , ¹⁵ , ¹⁶

To date, research into the UT of medical professionals has focused on undergraduate medical students and experienced clinicians. ⁷ , ¹⁴ , ¹⁷ , ¹⁸ , ¹⁹ Medical students are known to experience a wide variety of uncertainties related to their education (e.g. what to learn amongst the body of medical knowledge and how to learn it effectively), professional identities and the inherent uncertainty of patient care. ²⁰ These diverse sources of uncertainty are one key difference reported between students' experiences of uncertainty and clinicians in more established careers. ²⁰

Research shows that experienced clinicians also struggle with uncertainty, ¹⁷ but that sources of uncertainty are more focused on the clinical aspects of patient care. ¹⁶ , ²¹ , ²² , ²³ , ²⁴ What happens in the transition between these career stages is less well understood, as research about the UT of newly qualified doctors is limited. Whilst developing a new UT scale, Hancock et al demonstrated some variation between the UT of medical students and newly qualified doctors. ¹⁰ Scale results suggested that doctors in their second postgraduate year were better able to tolerate uncertainty when compared to medical students in years one, three and four of their degree. ¹⁰ As this was conducted via a cross‐sectional questionnaire, the nature of the uncertain experiences and the influential factors were not explored, leaving a gap in our understanding of uncertainty across the medical career continuum.

The movement from medical student to the doctor is recognised as a significant transition. ²⁵ , ²⁶ Newly qualified doctors may feel under‐prepared for the clinical aspects of their role, and experience challenges related to new work environments, professional identity development and navigating professional relationships. ²⁷ , ²⁸ This, alongside other transition periods in medicine, are associated with negative outcomes for doctors, including stress and burnout. ²⁵ , ²⁶ , ²⁹ Periods of transition are also associated with negative impacts for patients. ³⁰ There is evidence of an increase in the death rate around the time of junior doctor changeover, ³¹ and although the mechanism behind these negative outcomes is not yet clear, it is known that periods of transition are associated with increased uncertainty. ²⁵ , ²⁶ Given the known links between low UT and negative outcomes, including burnout, ⁷ exploring how doctors experience uncertainty during these transition periods could shed light on how to mitigate such negative outcomes. This may be particularly pertinent during the transition from medical student to doctor, given the high incidence of burnout amongst junior doctors. ³² , ³³

Following the completion of a medical degree in Australia (the context of the present study), graduate doctors complete an internship year to attain general registration. Therefore, for the purposes of this paper, the transition from medical student to doctor will be referred to as the transition to internship (TTI). During their first year of practice, doctors complete clinical rotations and receive support, feedback, teaching and assessment to ensure their preparedness to progress to vocational training and independent practice. ³⁴

In summary, this research seeks to answer the question ‘How do newly qualified doctors experience uncertainty during the TTI?’. This study used Hillen et al’s integrative UT model as the conceptual framework, ¹ and we, therefore, aimed to explore the sources of, responses to and moderating factors of uncertainty (defined in Table 1) as described by interns. The integrative UT model is widely used in health professions research, ¹⁸ , ²⁰ , ³⁵ , ³⁶ and was developed from an extensive literature base including prior research into clinical uncertainty. ²¹ This model's breadth allowed us flexibility to inductively identify themes and conceptualise the key UT components in this population. This research may ultimately support the development of an evidence‐based framework for educators, supervisors and employers to support doctors with managing uncertainty and developing UT during the TTI.

TABLE 1.

Definitions of components of the integrative model of uncertainty tolerance (UT) developed by Hillen et al(1).

UT model component	Definition
Sources of Uncertainty	Properties of information that lead to perception of uncertainty. Specific sources include complexity (information with multiple interacting elements that limit understanding), ambiguity (lack of reliability, credibility or adequacy of information) and probability (the indeterminacy or randomness of future outcomes). Also commonly known as stimuli of uncertainty.
Responses to Uncertainty	The cognitions, emotions and behaviours that occur following the perception of uncertainty.
Moderators of Uncertainty Tolerance	Factors which influence how a person perceives and responds to uncertainty. Categorised into stimulus, individual and situational characteristics and sociocultural factors.

2. METHODS

2.1. Study design and ethical approval

Aligned with our worldviews and research that suggests experiences of uncertainty are, at least in part, socially determined and influenced by context, ¹ , ¹⁸ , ³⁵ , ³⁷ we took a social constructionist view to explore newly qualified doctors' experiences of uncertainty during the TTI. Data were collected through semi‐structured interviews with participants experiencing this transition.

Institutional ethical approval was granted for this research (Project ID 20933).

2.2. Study context

Participants graduated from a single Australian medical school, which includes both undergraduate and postgraduate entry streams. Three participants were postgraduate entry medical students, whereas 10 participants entered medical school as undergraduates. Participants commenced practice as intern doctors in January 2021 across health care networks in Australia (predominantly in the state of Victoria).

At the time of data collection, intern doctors in Australia completed 47 weeks full‐time equivalent in clinical rotations including medicine, surgery and emergency care. ³⁴ Similar to the UK Foundation Programme, interns have not yet been selected for a specialty training programme. ³⁸

2.3. Participant selection

Participants were purposefully sampled due to their role as newly qualified doctors and their participation in a prior research project exploring medical students' experiences of uncertainty. ¹⁸ , ²⁰ , ³⁶ For the present study, participants involved in the prior research as final‐year students, who had provided contact details for study follow up, were invited via email to a semi‐structured interview early during the internship (March–May 2021). The invitation email offered a $100 AUD gift card following interview completion. Of the 15 prior participants contacted, 13 participated in this study. Participant demographics (collected as part of the prior study ²⁰ ) and interview characteristics are presented in Table 2.

TABLE 2.

Participants' demographics and interview characteristics. *N. B one participant completed internship part‐time. Weeks into internship for this participant are adjusted to the full‐time equivalent, with the change not indicated to maintain anonymity.

Interviewee (pseudonym)	Gender	Weeks into internship at the time of interview	Duration of interview (hour: minutes: seconds)
Adrian	M	8	1:09:49
Ali	M	9	1:10:56
Cathy	F	11	1:07:25
Chara	F	8	1:06:34
Chen	M	7	1:09:13
Darsh	M	13	1:04:18
Emily	F	10	1:03:31
May	F	9	1:11:26
Nisha	F	8	53:52
Olivia	F	13	46:53
Pallavi	F	7	50:11
Patrick	M	7	42:32
Victoria	F	9	1:01:30

2.4. Semi‐structured interviews

Individual semi‐structured interviews were utilised to facilitate a deep understanding of participant experiences. ³⁹ GS facilitated all interviews and was known to participants from prior research. ¹⁸ , ²⁰ , ³⁶ Interviews were conducted via Zoom (version number 5) to accommodate diverse participant and researcher locations.

Interview questions were designed by the research team (GS, ML and Dr Mahbub Sarkar [see acknowledgements]) and informed by prior research on UT and transitions in medical education. Table 3 summarises the interview protocol.

TABLE 3.

The semi‐structured interview protocol with example questions and responses. All excerpts are drawn from Pallavi's (pseudonym) interview. * TTI = transition to internship.

Aim of statement/Question	Example of interviewer statement/question	Excerpts of example participant responses
Interview overview and orientation	“I'm going to be asking you some questions about how you've experienced uncertainty during your TTI”	‐
Elicit participants' definitions of the ‘TTI’	“Can I get you to describe what TTI means to you?”	“… going from learning and not really having a lot of responsibilities, to actually performing tasks and actually being responsible for the care of patients.”
Offer participants the research team's definition of the ‘TTI’	“The changes that occur associated with moving from the role of a final year medical student to that of an intern doctor. This encompasses an increase in responsibility and independence, and is often associated with struggles or challenges, and an intense period of learning. There is no set time frame, but rather the transition is a dynamic process impacted by the workplace and interactions with the people in it.”	‐
Broadly explore participants' experiences of uncertainty during the TTI	“Can you tell me about your experiences of uncertainty during your TTI?”	“…it is quite an uncertain time. Probably more so than last year. I think a lot of the uncertainty though is more aimed at rather than being about actual medical knowledge, it's more of the uncertainty about … procedures and protocols.”
Deeper, participant‐guided exploration of experiences of uncertainty during the TTI	Sources of uncertainty “Can you provide some examples/any more examples of scenarios in which you have felt uncertain during your TTI?”	“…a lot of the uncertainty that I've had has been to do with I guess, procedures and my role as an intern … what's within my scope of practice, and what's outside of my scope, and so a lot of the uncertainty has been about you know, what can I do without first running it by someone else?”
	Responses to uncertainty “Thinking about the uncertain experiences you’ve described so far in relation to the TTI, can you tell me about how you responded to the uncertainty in your thoughts, emotions and behaviours?”	“… emotions wise, it has been probably my biggest source of stress in the workplace …”
	Moderators of uncertainty “Can you tell me about the factors that impact or influence your uncertainty now that you’re an intern or helped you transition to being an intern?”	“I think that the orientation provided by both the hospital network that you go to work at, as well as the particular individual units, can have a big say, or sway over your experience of uncertainty.”
Longitudinal experiences of uncertainty during the TTI	“Have your experiences of uncertainty changed in any way across your TTI?”	“I think … in the process of becoming more experienced, they're reducing in … the number and frequency of uncertain situations.”
Reflections on preparedness for uncertainty during the TTI	“Given your experience with uncertainty since starting internship, can you tell me about how you think medical school did or didn’t prepare you for the uncertainties you’re now experiencing?”	“… medical school did prepare me for the uncertainty, particularly that final year where the focus was not so much on learning medical knowledge and content, but more about how to function as a doctor.”
	“What advice would you now give to medical students or even your former self in relation to managing or coping with uncertainty during medical school?”	“… during medical school, I found that … the process of reflective learning has been really probably the most helpful to me, in terms of dealing with uncertainty.”
Conclusions and final reflections	“Do you have any final comments or questions for us as researchers that you think would be helpful/we haven’t covered yet?”	“No, I think it's been, yeah, that's been about all.”

Audio recordings were initially transcribed using Otter.ai. ⁴⁰ Transcripts were manually checked and edited by MD.

2.5. Data analysis

Framework analysis was used to analyse the data, ⁴¹ with the integrative UT model used as the guiding conceptual framework. ¹ There are five stages to Framework Analysis ⁴¹ : familiarisation, identifying a thematic framework, indexing, charting and mapping and interpretation.

The familiarisation stage involved immersion in the data to gain a preliminary understanding of the whole dataset. During this stage, all interview recordings and transcripts were listened to and read by MD, who documented initial coding ideas. GS was familiar with the data through her role as the interviewer.

A structured coding framework was developed during the second stage. MD was guided by the research aims, knowledge of the existing literature and notes from the familiarisation stage to produce an initial codebook. Components of the integrative UT model (i.e. stimuli, moderators and responses) were used as initial parent codes. ¹ Aligning with the integrative UT model, ¹ uncertain stimuli were initially sub‐categorised into probability, ambiguity or complexity and responses were sub‐categorised as cognitive, emotional and behavioural. Moderators of uncertainty were sub‐categorised based upon whether they were related to the stimulus characteristics, individual characteristics, situational characteristics or socio‐cultural factors.

The codebook was refined over several months following discussions amongst the author team (MD, GS and ML) and reflexive engagement with the data. Multiple iterations of the codebook were refined through abductive analysis, where the analytic process oscillated between deductively applying the preliminary framework based on the integrative UT model, and inductively adding and adjusting codes based on participants' descriptions.

During the indexing and charting stages, MD systematically coded each transcript using NVivo qualitative data analysis software (release 14.23.0). MD met fortnightly with GS and monthly with ML to discuss any questions and challenges during the coding process, refine the codebook and name themes.

The final stage of mapping and interpretation involved analysing the dataset as a whole to identify patterns across themes and provide explanations for findings. This stage was assisted by NVivo, which identified the co‐location of themes and subthemes within the data, highlighting potential links between UT components. We drew comparisons with existing medical education literature to identify similarities and differences between the experiences of participants and other professional groups. This stage also included searching the literature to identify theories beyond the construct of UT that could explicate the uncertainties of transition periods. We identified Mezirow's Transformative Learning Theory as relevant to explaining participants' experiences, ⁴² , ⁴³ and drew on this theory when developing the educational implications of our findings. The final stage continued throughout the writing of this paper.

We used the concept of information power to inform our data collection and analysis. As described by Malterud et al, ⁴⁴ the concept of information power considers five dimensions that inform the richness and relevance of qualitative data and, therefore, the sample size. These five dimensions are study aim, sample specificity, established theory, quality of dialogue and analysis strategy. ⁴⁴ A study will have low information power and thus require more participants if the study aim is broad, specificity of participants is sparse, theory is not engaged, dialogue is weak and cross‐case analysis is used. We determined that our sampling was appropriate for this research due to the focused research question that was specific to a particular group of individuals experiencing similar contexts (i.e. being newly qualified doctors) and the longitudinal nature of participants' engagement with the larger study. Our sample size was also supported by the theoretically grounded approach (i.e. engagement of the integrative UT model) and the established relationship between the interviewer and interviewees, which promoted strong dialogue.

2.6. Researcher characteristics and reflexivity

MD is an academic clinical fellow in general practice with an MSc in Clinical Education, who completed the UK equivalent of TTI in April 2020. ML is an anatomy educator and health professions education (HPE) researcher. GS is an anatomy educator, medical practitioner and HPE researcher.

As the author team, we completed a reflexivity exercise to understand the perspectives that we brought to this project. ⁴⁵ We identified that we all held either constructivist or interpretivist worldviews and agreed that qualitative research was ideal to explore this topic because of the social influence and dynamic nature of experiences of uncertainty. We identified that the lived experience of MD and GS as medical practitioners may influence their perspectives of UT during the TTI and that this contrasted with ML's rich theoretical and educational experience related to medical education and UT. We all had experience with qualitative and UT research to different degrees and based in different health care settings (UK, USA and Australia). When we met throughout the study, we aimed to challenge each other's beliefs and perspectives to reflexively engage with the data, particularly in relation to our diverse lived and theoretical positioning.

3. RESULTS

We identified themes and subthemes (Table 4) across all components of the integrative UT model relating to participants' experiences of uncertainty during the TTI. ¹ To illustrate our findings, we use quotations under the pseudonyms described in Table 2, and italics to indicate themes and subthemes.

TABLE 4.

Summary of themes and subthemes according to the components of the integrative UT model during newly qualified doctors' transition to internship.

UT model component	Themes	Subthemes
Sources of Uncertainty	Novel scenarios	New tasks
		New work environments
		New responsibilities
	Role uncertainty	Individual role uncertainty
		Interprofessional role uncertainty
		Future role uncertainty
	Clinical uncertainty	Patient care uncertainty
		Gaps in clinical knowledge and skills
Responses to Uncertainty	Behavioural responses	Asking for help
		Information seeking
	Cognitive responses	Acceptance of uncertainty
		Reflecting on uncertainty
		Learning from uncertainty
	Emotional responses	Stress
		Self‐doubt
Moderators of Uncertainty Tolerance	Sociocultural factors	Support accessibility
		Shared uncertainty
	Situational factors	Available time
		Perceived stakes
	Individual factors	Knowledge and skill base
		Expectations of self
	Stimulus factors	Patient familiarity

3.1. Sources of uncertainty

The sources of uncertainty, or the underlying reasons why participants perceived uncertainty, related to novel scenarios, role uncertainty and clinical uncertainty.

3.1.1. Novel scenarios

Novel scenarios were described as a source of uncertainty by all participants, irrespective of the number of weeks into the internship at the time of the interview. Uncertainty in this theme stemmed from experiences participants perceived as “new” in the context of their role as interns, with some participants highlighting this as a defining feature of the TTI:

“[The transition to internship is] just a whole lot of new, uncertain scenarios” ‐ Pallavi.

Subthemes of novelty scenarios were new tasks, new work environments and new responsibilities.

New tasks were the technical or administrative parts of interns' work that they had not previously undertaken, such as new navigating health information systems and processes:

“It's a very practical uncertainty where I just wasn't sure how to use a paper charting system or how to order echoes … the very logistical aspect of [the intern role].” ‐ Olivia.

At the level of their basic surroundings, participants also reported feeling uncertain about finding their way around their new work environments. This included not knowing where to find their pager, where to sit in an office and where to find basic equipment required to perform their role.

Participants even commented on a sense of uncertainty when doing a familiar task but for the first time in their new position. This perception was typically attributed to their new responsibility and relative independence:

“…you can be really good at a procedure or a certain skill, like taking blood from a patient, but doing that independently […] is a very different experience.” ‐ Nisha.

3.1.2. Role uncertainty

Participants described uncertainty about their professional role, including individual, interprofessional and future role uncertainties. Role uncertainties seemed distinct from the newness of the position, as they were described as persisting beyond participants' first experiences as interns.

Individual role uncertainty encompassed participants' uncertainties about their scope of practice and to the extent to which they were achieving the expectations that others had of them in their role:

“That realisation that every team has a different expectation of their interns. So I definitely ask relatively frequently, is this something that I can do … is this something that is an intern job?” ‐ Olivia.

A key feature of the intern role described by participants was the need to manage multiple interacting tasks. Although they may have been asked to complete such tasks as part of their role, individual role uncertainty arose for participants when they were unsure if they were successfully managing these tasks to the level expected of interns, and at what point the tasks extended beyond their scope of practice. Uncertainties about the scope of practice were described as complex, with interns weighing up multiple factors to determine how and when to escalate patient concerns, as well as understanding the expectations for doing so, irrespective of their individual clinical experience:

“While I know it's important to escalate things early and ask people theoretically, if people aren't there, or you have to, you know, make that phone call to bother someone to ask for advice, it's a lot harder in reality, to sometimes ask for help earlier, so you kind of are left feeling uncertain about whether you should just go ahead and do something.” ‐ Victoria.

Participants referred to interprofessional role uncertainty when extending their discussion on role uncertainties to include how they perform their role in relation to other doctors and health professionals. This discourse included the professional etiquette required of intern doctors and referenced the “unwritten rules” of working alongside those who may have different approaches to patient care, roles and responsibilities, and levels of experience:

“…a lot of the unwritten rules around sort of interpersonal relationships at work in the workplace are probably the biggest area that … I found a little bit of uncertainty with … I'm, you know, sometimes twenty, thirty years younger than some of the nurses I work with, you know, how are you supposed to ask them to do something for you without making it seem conceited?” ‐ Chara.

Participants additionally reported feeling uncertain about their future roles. Such uncertainties included the near future, for example, predicting how they would manage the remainder of the internship, and longer‐term uncertainties, such as what their future career and personal lives may entail:

“…that's a big part of being uncertain as an intern, that you know, you don't know what your next year will look like, you don't know if you'll be in the same hospital, you don't know what your next five years will look like, you don't know what field you want to specialise in.” ‐ Nisha.

3.1.3. Clinical uncertainties

Participants recounted uncertainty about the clinical aspects of their role, i.e. the evaluation and treatment of patients. These uncertainties related to gaps in clinical knowledge and skills, and patient care.

Participants described gaps in clinical knowledge and skills as a key reason for feeling clinically uncertain. The gaps described by participants included recalling previously learnt factual medical information required for their role, and how to perform skills such as clinical procedures and examinations. Participants predominantly ascribed this uncertainty to a relative lack of clinical experience. The gaps were also described in relative terms, wherein the uncertainty stemmed not from an absolute knowledge deficit but challenges with the application or analysis of knowledge in relation to patient care:

“And even for simple questions, such as blood sugar management or insulin dosing, I'd find that, that I would be uncertain about what specifically to do in that particular instance, even if I do have a theoretical knowledge, it's a bit, it's a bit of a jump to apply that in a more practical sense.” ‐ Patrick.

By contrast with how gaps in clinical knowledge and skills may be ameliorated through learning and experience, patient care uncertainty addressed the inherent uncertainties of clinical practice that are attributable to factors such as the complexity, unpredictability and changing nature of medical knowledge. Participants described patient care uncertainty arising from all stages of the patient care journey, including diagnosis, prescribing and discharge planning. An example of diagnostic uncertainty described by multiple participants related to presentations of abdominal pain. Participants recalled being uncertain about diagnosis in this context because they recognised the wide variety of potential causes for abdominal pain, and that the correlation between symptoms and condition severity was not always clear:

“You can have someone with just a little bit of abdominal pain, with, you know, a massive abscess or, you know, appendicitis or something, or you can have someone with severe pain that has nothing really going on.” ‐ Pallavi.

Participants' accounts of uncertainty related to the clinical aspects of their role were, however, less dominant in comparison to other sources of uncertainty.

3.2. Responses to uncertainty

3.2.1. Behavioural responses to uncertainty

Participants predominantly described acting upon their uncertainty by asking for help and information seeking. When participants discussed asking for help, they typically sought this from doctors more senior than themselves such as consultants, registrars and resident medical officers (RMOs):

“I probably was still like in the medical student mode. You know, I keep asking [the registrar] about the, what should I do? And then what do you think is happening? What does the x‐ray show?” – May.

Participants less typically reported asking peers or other members of the multidisciplinary team (MDT), such as pharmacists in relation to medication uncertainties.

Although some participants detailed the thoughts and actions that preceded the act of asking for help, such as forming carefully considered questions for senior colleagues, other participants reported getting help as an almost immediate reaction to uncertainty:

“I feel like there have been times where I haven't even considered clinically myself what might be happening to this patient, like and even considered like a differential diagnosis. Because I've just automatically been like oh, I should tell my reg[istrar] about this.” ‐ Cathy.

The other dominant behaviour described in response to uncertainty was the act of information seeking in an attempt to reduce their perceived uncertainty. This included reading patient notes, ordering investigations, reviewing clinical guidelines and referring to other sources of information about medical conditions:

“… I've moved [the textbook] OnCall to my phone … so it's a lot of sort of tippy tapping in the corner as soon as you've seen a patient being like, what do they have?” ‐ Chara.

Both behavioural responses of uncertainty were typically described in relation to gaps in clinical knowledge and skills when the uncertain source was identified.

3.2.2. Cognitive responses to uncertainty

The cognitive responses to uncertainty described by participants related to acceptance of uncertainty, reflection on uncertainty and learning from uncertainty.

Acceptance of uncertainty was the predominant cognitive response reported by participants. Participants described appreciating the inherent presence of uncertainty in the clinical environment and the importance of managing uncertainty as part of practicing medicine:

“I think I've realised that there are a lot of unknowns in medicine, like, there are a lot of times where people don't know exactly what's happening […] I think I've become a little bit more tolerant of like, areas of greyness, rather than having to be like black and white.” Cathy.

Participants also recalled cognitively responding to uncertainty by reflecting on uncertainty, including through reflective discussions with friends, family, mentors and peers and independent reflection. Through the process of reflection, participants were able to offload negative emotions associated with uncertainty, and instead rationalise or normalise their experiences of uncertainty:

“I think just trying to self‐reflect and like, reflect on your feeling of uncertainty and telling yourself that, like, it's kind of normal to feel uncertain.” ‐ Victoria.

Learning from uncertainty was described by participants typically in circumstances that prompted a degree of interest or curiosity. These scenarios typically related to the teamwork involved in clinical problem solving when uncertainty was shared by multiple team members and when the uncertainty was not perceived as placing a patient at immediate risk of harm, thereby allowing the space for learning:

“So that was yeah, when like, yeah, that sort of element of problem solving when it wasn't sort of acute was fun.” ‐ Emily.

Cognitive responses to uncertainty typically related to role uncertainty and clinical uncertainty as the uncertain source.

3.2.3. Emotional responses to uncertainty

Although participants' descriptions of their responses to uncertainty predominantly addressed behavioural and cognitive responses, some emotional responses to uncertainty were described. The two key emotions reported were feelings of stress and self‐doubt.

Descriptions of stress in response to uncertainty ranged from a sense of worry to physical sensations of anxiety that participants attributed to a stress response:

“I felt in the first two weeks of internship, I kept feeling dizzy … kind of like when you're in a lift, or when you're in a really high building, and you can kind of feel that little sway, or that little like, lightness, light headedness … I've kind of put it down to a possible like, anxiety related response.” ‐ Cathy.

Self‐doubt in response to uncertainty included participants feeling as though their uncertainty was a result of gaps in their clinical knowledge or skills, rather than naturally occurring in patient care. For instance, participants described unexpected events, such as a patient deteriorating, and feeling as though it was their lack of ability to predict this, which led to the perception of uncertainty and feelings of self‐doubt. For some, such events caused participants to further question their actions and abilities:

“That's maybe the part of uncertainty where I've sort of gone, you know, previously where I'd probably discharge patients without too much of a second thought, you know, now I've started to go a little bit more actually, you know, could there be anything else? Are you sure there's nothing else?” ‐ Chara.

Where emotional responses were discussed alongside the source of uncertainty, they typically related to novel scenarios and role uncertainty.

3.3. Moderators of uncertainty tolerance

Factors that moderated participants' responses to uncertainty were categorised as relating to the socio‐cultural setting, the situation, the individual or the stimulus.

3.3.1. Sociocultural factors

The sociocultural factors moderating participants' responses to uncertainty were related to support accessibility and shared uncertainty. Participants reported feeling more comfortable with uncertainty knowing that support was available from individuals that not only had the requisite knowledge and experience but were also approachable and personable. Conversely, when interns felt as though they lacked support, their perceptions of uncertainty increased:

“I guess the greatest periods of uncertainty are when I'm at the hospital somewhat independently, by myself, especially on evening shifts. During those periods, there's often not an easily accessible registrar to ask for advice.” ‐ Patrick.

Participants predominantly spoke about support from more senior doctors but also mentioned support from peers, family, friends and other members of the MDT. Support was mostly described as ad hoc rather than a formalised intern support programme and included offering reassurance, giving a second opinion, providing feedback or just listening. Even when support was not needed or the supporter not physically present, just knowing that support would be available if needed was reported to moderate uncertainty.

When describing shared uncertainty, participants recounted how their experiences of uncertainty were moderated by observing and understanding their colleagues' experiences of uncertainty. This included when other team members experienced clinical uncertainty at the same time as the participant and when colleagues recounted past experiences of uncertainty relevant to the participants' roles. The result of this shared uncertainty was participants feeling more comfortable with their own uncertainty:

“And I think everyone has largely had pretty similar experiences in the first few weeks of just feeling stressed and not sure of what they're doing. And that like, communal sense of uncertainty makes me feel better.” ‐ Victoria.

Across all categories of moderators, it was these socio‐cultural factors that participants recalled as having the predominant influence over their experiences of uncertainty.

3.3.2. Situational factors

The situational factors that influenced participants' experiences of uncertainty were available time and perceived stakes. The influence of available time on participants' responses to uncertainty was described in different ways. Participants typically reported feeling less supported to manage uncertainty when there was less time available to them. However, while some participants reported that having less time increased their feelings of stress, others reported that having less time meant that they had less of an opportunity to feel stressed:

“I can recall earlier on in the rotation, in the rotation, being fairly uncertain and having anxiety around the uncertainty, whereas now you'll still face uncertain situations, but you just don't really have the time to feel anxious.” ‐ Chara.

The perceived stakes, or potential for patient harm in a given situation, also appeared to influence participants' experiences of uncertainty. A higher‐stakes scenario identified by several participants was undifferentiated abdominal pain that could be due to a life‐threatening pathology. In such scenarios, participants typically described feeling stressed and asking for help or escalating concerns. However, some interns also discussed their significant discomfort in lower‐stakes situations as they felt more unsure about the appropriateness of asking for help:

“…this isn't threshold enough to call someone, but this isn't low enough for me not to be worried about it either. So I guess it's that middle range where the anxiety sort of creeps up a bit more.” ‐ Ali.

3.3.3. Individual factors

Characteristics of themselves that participants described as influencing their experiences of uncertainty were their knowledge and skills base and their expectations of self in their role as an intern. The most influential individual factors described by participants was their knowledge and skills base built through experiences across medical school and internship so far:

“I think an alleviating factor for uncertainty, I guess regardless of internship, has always been experience. You know, even if you have never done one, the more you've seen the … less uncertain you are.” ‐ Adrian.

Although some participants described the influence of their knowledge and skills in general, others described the role of gaining experience specific to their clinical rotations. Multiple participants detailed how their perceptions of uncertainty would reduce towards the end of a clinical rotation, and how they learnt transferable skills that helped them to adapt to subsequent rotations:

“The first time I had to adjust to a new role, I spent a lot longer being uncertain. But once I had that first experience of adjusting to … one role, I was able to probably adjust a lot faster to…the second role that I've had now.” ‐ Olivia.

Expectations of self encompassed participants' beliefs about their performance and whether this met the goals and standards they set for themselves. If participants expected they should have the knowledge or skills to manage an uncertain situation, they described experiencing greater discomfort when compared to uncertain scenarios they perceived as being beyond their expectations:

“I feel like one thing that comes up in my mind is, is this something I should know? Or is this something I shouldn't? And then based on that, I kind of sort of almost go in two modes where, if it's something I feel like I should know, it's probably a little bit more anxiety inducing if anything, where if it's not, I feel like, at least I know that asking for help early is not such a bad thing.” ‐ Darsh.

3.3.4. Stimulus factors

Participants only discussed one moderating factor related to the stimulus of uncertainty, which was patient familiarity. This factor was predominantly related to descriptions of clinical uncertainty, with participants describing how not being familiar with a patient and their medical history increased their feelings of uncertainty. Some participants demonstrated their insight into this moderating factor when they reflected upon the process of information seeking to increase their familiarity with the patient case:

“The more I spend reading the file and gathering the information before I actually see the patient, the more certain I feel when I'm going to see the patient” – Adrian.

So, even though the TTI may be characterised by “just a whole lot of new, uncertain scenarios”, there are a variety of factors that can influence how interns experience and respond to uncertainty.

4. DISCUSSION

4.1. Key findings in relation to the UT literature

During the TTI, newly qualified doctors transform from medical students to practising clinicians. Although this transition period is known to be challenging and associated with negative outcomes, ²⁵ , ²⁶ , ²⁷ , ²⁸ this study fills a gap in the literature by exploring this period through the lens of UT. ¹ Although uncertainty is ever present across medicine and health care, ¹ , ⁷ our findings highlight the uniquely uncertain experiences of newly qualified doctors, and in doing so, shed light on how this group may be better supported to learn skills for managing uncertainty that they will require throughout their careers. Aligned with the integrative UT model, ¹ we discuss these experiences concerning the sources of, responses to and moderators that influenced interns' experiences of uncertainty.

We identified that sources of uncertainty experienced by doctors during the TTI stemmed from novel scenarios, role uncertainties and clinical uncertainty. Although these sources of uncertainty generally align with those identified in studies with medical students, ²⁰ , ⁴⁶ our subthemes elucidate the specific sources of uncertainty for newly qualified doctors. Although both medical students and interns describe uncertainties about their knowledge and skill base and professional role, interns' discourse included uncertainties about applying knowledge within the context of newly increased responsibilities, learning to juggle multiple complex tasks and navigating the tensions of being both a new health care professional and one with responsibilities to delegate to tasks to others (e.g. nursing staff). Like medical students, ²⁰ uncertainty related to patient care was less typically described in our study, however, this is the predominant source of uncertainty described in studies with senior doctors. ¹⁶ , ²¹ , ²² , ²³ , ²⁴ This difference may relate to the early stage of the interns' transition, meaning that uncertainties about novel scenarios instead tended to dominate discussions. Importantly, many such novelties are potentially reducible (e.g. through more relevant orientation programmes), ¹⁵ , ¹⁸ , ²⁰ so it is pertinent to consider whether reducing these would enable interns to devote a greater portion of their role to learning how to manage the clinical uncertainties that will form an important component of their work as they gain experience and seniority.

In response to uncertainty, interns reported feelings of stress and self‐doubt and described actions such as asking for help and information seeking. Cognitive responses to uncertainty included accepting the place of uncertainty in health care and reflecting on and learning from uncertain experiences. Similar to how medical students described responses to uncertainty, ³⁶ , ⁴⁶ it was difficult to identify whether emotions and actions helped or hindered interns' uncertainty management. Although negative emotional responses, particularly when they are prolonged, can negatively impact one's capacity to manage uncertainty, ³⁷ some level of discomfort and stress is shown to be typical in managing uncertainty. ²⁴ , ³⁶ , ⁴⁶ Research in the field of psychology supports that humans tend to respond to uncertainty, at least initially, with stress and fear, ⁴⁷ and a degree of stress or self‐doubt may also help optimise interns' performance and uncertainty management. ²⁴ Hence, understanding interns' actions and cognitive responses to uncertainty, alongside their emotional responses, may yield greater insights into understanding how they manage and cope with uncertainty. ³⁶

Interns' descriptions of asking for help, a dominant behavioural response identified in this study, may be considered an appropriate response uncertainty during the TTI given the interns' relative lack of experience and junior position within medical teams. Although some participants described carefully formulating clinical questions and seeking information to aid their escalation and referral of patients to registrars and consultants, others described asking for help as an immediate or almost reflexive response to uncertainty. This is comparable to the decision deferral described in medical students, ³⁶ wherein some students described deferring decisions to more senior clinicians immediately, and others only after key information to guide the decision had been sought. Exploring how senior medical students and newly qualified doctors make decisions to escalate their uncertainty may be important for supervisors to understand and facilitate more directed support for developing interns' uncertainty management skills.

Of all response types, participants' descriptions of their cognitions are perhaps the most adaptive and provide insights into how this population is learning to cope with uncertainty. Cognitive responses included acceptance of uncertainty in health care, which prior studies demonstrate can be developed through experiences with clinical uncertainty during medical school. ³⁶ , ⁴⁶ In addition to this acceptance, participants described the role of reflection as a means of coping with uncertainty during the TTI. Although reflective learning is typically included in medical school curricula and postgraduate training frameworks, ⁴⁸ , ⁴⁹ the reflections described by interns were largely informal and focused on processing the emotions that were evoked during uncertain scenarios. Evidence supports that reflective learning is a key educational approach to developing skills for managing uncertainty. ¹⁵ , ¹⁸ However, frameworks for reflective learning emphasise going beyond recalling and processing emotions to critically reflect on the significance of events and their meaning for future learning and practice. ³⁶ , ⁴⁸ , ⁴⁹ So, while reflection was identified in this study, interns' descriptions suggest there is a gap between their approaches to reflection and the best practice for how reflections can support the development of UT.

Interns also provided insights into the factors that influence or moderate their perceptions of, and responses to uncertainty. These moderators support the construct of UT in health care being influenced by the sociocultural context. ¹ , ¹⁸ , ⁴⁶ Key factors that supported interns in managing uncertainty included sufficient access to support (e.g. knowledgeable and personable registrars during after‐hours shifts), sharing uncertainty about patient care across a health care team, and having a work environment where perceptions of available time and stakes related to patient care were concordant with the demands and expectations of their role. In their update to the integrative UT model focussed on psychological well‐being, Hancock and Mattick incorporate cultural and workplace factors as moderators of the development of burnout and mental health disorders related to uncertainty. ³⁷ Our findings extend this work by suggesting that these factors may specifically include the amount and quality of clinical support, staffing ratios that facilitate manageable workloads and rostering that facilitates patient familiarity and continuity of care. Although these workplace factors may be increasingly challenging to address due to workforce shortages in many contexts, ⁵⁰ they may help further explain the relationship between UT and burnout. ³⁷

4.2. Relation to theory: UT and transformative learning

Although the integrative UT model is frequently used in health professions education research, it is not intended as a “grand unifying theory” of UT. ¹ The integrative UT model focuses on clinical uncertainty and health care, and therefore does not address the relationship between education, learning theories and UT. ³⁵ Recent work extending the integrative UT model considers how learning theories, such as those with experiential, constructivist and social bases, may relate to the integrative UT model and can be used in association with it to develop educational activities that support UT development. ⁴³ Given that newly qualified doctors are in the midst of a major career transition, transformative learning theory may be a helpful addition to the integrative UT model that further aids in understanding the uncertainty experienced during transition periods and the educational implications of our findings. ⁴³ , ⁴⁴

Transformative learning theory, typically attributed to Mezirow, ⁴³ , ⁴⁴ explains how learners adjust or transform their perceptions and understandings as new information is received. The theory has a constructivist basis and thus includes how learners build knowledge by integrating new information with existing understandings. Transformative learning theory involves a four‐stage process starting with a disorientating dilemma or experience, which leads to critical reflection, rational dialogue and, eventually, action. Each of these stages may be mapped to the components of the integrative UT model, ⁴³ , ⁵¹ with the disorienting dilemma representing the source of uncertainty, critical reflection and rational dialogue representing moderators and actions representing the response to the source of uncertainty.

Crucially, a disorientating dilemma needs to be sufficiently challenging and uncertain (e.g. unfamiliar, complex or ambiguous) that it leads a person to question their knowledge and prior learning. In the context of our findings, the disorientating dilemma may be conceptualised as the experience of the TTI and its accompanying uncertainties, such as how to apply prior learning within the context of new responsibilities. Although experiencing the disorientating dilemma may promote a degree of learning, an effective transformation of understanding requires further stages of transformative learning.

The next stage, critical reflection, is a key component of multiple learning theories, ⁴³ and perhaps has the greatest evidence for educational approaches that support skills for managing uncertainty. ¹⁵ , ¹⁸ Critical reflection is a deeper process than the reflections on emotions described by interns in our study and involves an individual questioning their prior experiences, assumptions and beliefs, which may lead to a revised or transformed perspective on managing uncertainty. ⁴³ Importantly, the process of critical reflection can be supported by educators and clinical supervisors through the provision of reflective prompts and feedback. For instance, some interns in this study described asking for immediate help in response to clinical uncertainty without evaluating the patient and developing differential diagnoses. Although asking for help and escalating concerns is an important part of an intern's role, critical reflection may help interns learn from such experiences and consider further approaches that they can take to manage clinical uncertainty as they gain experience.

Feedback on the interns' critical reflection can then be used to ensure that their reflection leads to learning. ⁴³ In transformative learning theory, the stage of rational dialogue involves the learner communicating with others (e.g. peers, more senior doctors, etc.) to support sense‐making of their new perspectives and inform their future actions for managing similar uncertainties. Rational dialogue that supports critical reflection should therefore form an important component of discussions between interns and their supervisors. Interns in this study identified accessible support and sharing uncertainty as key moderators of uncertainty. Sharing uncertainty by more senior doctors who support interns could form a further important part of rational dialogue, and could be achieved through approaches such as intellectual candour, wherein vulnerability (i.e. sharing one's own experiences of uncertainty) is balanced with credibility (i.e. describing expert approaches to managing uncertainty). ¹⁵ , ⁵²

Action, or the final stage of transformative theory, considers how the learner applies their transformed understanding to guide their actions in the future. For interns to enact this final stage, they will require opportunities to manage uncertainty where they can incrementally develop their skills. The interns in this study described how differing expectations across different work locations, specialties and individual supervisors caused them to question their scope of practice. Clarifying interns' scope of practice in relation to training frameworks and individuals' skill base may be important for supervisors to help ensure that interns can act to develop uncertainty management skills across their internship.

For all stages of transformative learning to occur, psychological safety is key. ⁵³ Without psychological safety, interns may fear the negative consequences of discussing their uncertainty with supervisors and mentors, such as unfavourable end‐of‐term assessments and references. Key strategies for supervising clinicians that can promote psychological safety when learning about uncertainty based on this research include role modelling UT by openly sharing and discussing their uncertainties, setting clear expectations around interns' scope of practice and learning goals, allowing adequate space and time to explore uncertainty and supporting a culture of feedback and reflection.

4.3. Educational implications

Integrating our findings with the UT literature and transformative learning theory, we prioritise the educational implications of this research for undergraduate medical education, intern educators and supervisors, employers and interns themselves.

Literature on how to prepare near‐graduating medical students for the TTI highlights the need for learner‐centred transition programmes, simulations and competency‐based assessments that authentically represent common intern activities and responsibilities. ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ For instance, Kalet et al describe a “night on call” competency‐based assessment wherein candidates complete OSCE stations designed to evaluate entrustable professional activities required for the transition to residency in the United States. ⁵⁶ Although this literature highlights the need to foster non‐clinical skills such as communication and critical thinking alongside clinical expertise as part of transition programmes and simulations, ⁵⁵ , ⁵⁷ there may be greater scope for these to explicitly incorporate skills for managing uncertainty. Examples based on this research could include scenarios where candidates need to prioritise multiple tasks, ask for help from senior colleagues to manage clinical uncertainty and navigate uncertain role boundaries in health care teams. This learning may be further enhanced when coupled with critical reflection focused on how the scenario can inform future uncertainty management. ⁵⁸ , ⁵⁹

Near‐graduating students might also benefit from a supported trial of intern positions. During the early stages of the COVID‐19 pandemic, final‐year medical students in the UK were invited to support the workforce in a protected position similar to that of an intern but were supernumerary and assigned a more senior buddy who provided additional support. ⁶⁰ The resulting evidence supports the idea that this experience increased doctors' preparedness for practice, ⁶⁰ , ⁶¹ and there is work in progress to evaluate the extent to which their UT contributed to this. ⁶²

Once newly qualified doctors commence practice, clinical supervisors are well‐positioned to support interns' transition to practice and the development of uncertainty management skills. Supervisors are encouraged to engage with interns about clinical uncertainty in a manner that promotes rational dialogue, to share their own relevant experiences of uncertainty and to set clear expectations for their career stage. ¹⁵ , ⁴² , ⁴³ Based on this research, setting expectations should address interns' uncertainty about their scope of practice for managing clinical uncertainty, and how this should develop across internship. To make the most of supervisory experiences, we encourage interns to engage in critical reflection on their uncertainties and work with supervisors to plan how their learning can be applied and developed throughout their internships. Training frameworks for internship and equivalent periods in other contexts may also be able to more explicitly incorporate skills for managing uncertainty and critical reflection.

Finally, employers and hospital administrators may also be able to support interns to develop skills for managing uncertainty during the TTI. This should include ensuring orientation programmes reduce the extraneous uncertainty related to interns' working environment, ¹⁵ , ¹⁸ including technical and administrative tasks. Rostering of medical staff should also ensure that interns have adequate and accessible support from more senior doctors and manageable workloads that include time for ongoing learning, feedback and critical reflection.

4.4. Strengths, limitations and future directions

Key strengths of this study include the dialogue between participants and GS facilitated by the longitudinal relationship developed through the prior studies, ¹⁸ , ²⁰ , ³⁶ and the engagement of reflexive, team‐based and theoretically informed framework analysis. The theoretical strength of our work supports that findings may be transferable to contexts with similar health care systems and training of newly qualified doctors (e.g. to the UK Foundation Programme). ⁶³ We did, however, encounter some methodological challenges and identify areas where further research is required to understand newly qualified doctors' experiences of uncertainty.

The cross‐sectional nature of our data collection posed limitations on our understanding of how interns' experiences change over the course of their TTI. Some participants addressed the temporality of their experiences concerning novelty and how this source of uncertainty re‐emerged when changing clinical rotations. Hence, future research could benefit from longitudinal approaches to explore interns' experiences of uncertainty.

Using the integrative UT model as a preliminary framework facilitated a broad exploration of the sources of, responses to, and moderators of uncertainty. ¹ Although we identified some patterns across the components of the integrative model, the retrospective nature of this research may have limited the depth of data needed for such links. We also encountered challenges in determining whether responses to uncertainty could be considered adaptive or maladaptive for managing uncertainty. Further research could explore these areas by engaging different methods (e.g. video‐reflexive ethnography to observe management, and heart rate monitoring to measure an indicator of stress) and by including the perspectives of those who work with and supervise interns. Utilising additional theories, like transformative learning theory, may be helpful when planning future studies. ⁴² , ⁴³

5. CONCLUSIONS

Positioned at the point of transition from medical student to practising doctor, the TTI was described as stimulating substantive and unique experiences of uncertainty for intern doctors. Although interns described experiences of clinical uncertainty, the predominant sources of uncertainty related to novel scenarios and their professional role. Participants typically responded to their uncertainty by asking for help but also described feeling stressed and reflecting on uncertain events.

Interns may be better supported to learn from clinical uncertainty if the numerous, non‐clinical uncertainties they experience are reduced (e.g. through orientation programmes offered by employers). Drawing on transformative learning theory, engagement with critical reflection may help interns cope with uncertainty and identify how they can progress their skills for managing clinical uncertainty. Critical reflection should ideally be supported by clinical supervisors and educators who engage with interns through feedback dialogues and share their own relevant experiences of uncertainty. Delving into doctors' longitudinal experiences of uncertainty at different career stages is now needed to better understand how UT evolves over time and to develop more specific interventions to support doctors at each stage.

AUTHOR CONTRIBUTIONS

Molly Dineen: Writing—original draft; writing—review and editing; project administration; formal analysis; visualization; data curation. Michelle Lazarus D: Conceptualization; funding acquisition; writing—review and editing; supervision; methodology; formal analysis. Georgina Stephens C: Supervision; conceptualization; investigation; writing—original draft; writing—review and editing; formal analysis; project administration; methodology; data curation.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to declare.

Dineen M, Lazarus MD, Stephens GC. Uncertainty experienced by newly qualified doctors during the transition to internship. Med Educ. 2025;59(10):1079‐1093. doi: 10.1111/medu.15692

DATA AVAILABILITY STATEMENT

Research data are not shared.