How Tolerance of Uncertainty Relates to Well-Being in Japanese Primary Care Physicians: A Cross-Sectional Study

ABSTRACT

Background

Medical uncertainty is inherent in clinical practice, especially in primary care where clinicians regularly face multimorbidity, ambiguous symptoms, and unpredictable care courses. Although tolerance of uncertainty (TU) has been associated internationally with resilience, job satisfaction, and decision-making, little is known about its relationship to physician well-being in Japan. In a medical culture that emphasizes precision and decisiveness, navigating uncertainty may be psychologically challenging. This study examined the association between TU and two dimensions of well-being—subjective well-being (SWB) and eudaimonic well-being (EWB)—among Japanese primary care physicians.

Methods

We conducted a cross-sectional online survey from March 1 to 31, 2023, targeting physicians on the Japan Primary Care Association mailing list (N = 4,207). The questionnaire included demographic items and three validated scales: the Short Intolerance of Uncertainty Scale (SIUS), the Subjective Well-Being Scale (SWBS), and the Eudaimonic Well-Being Scale (EWBS). One free-text item explored emotional responses to high-uncertainty situations. Quantitative data were analyzed using correlation analysis and structural equation modeling (SEM), and qualitative responses underwent thematic analysis.

Results

Out of 152 responses, 150 were valid. The SIUS score showed a significant negative correlation with both SWBS (r = –0.433, P < 0.001) and EWBS (r = –0.259, P = 0.001). SEM confirmed these associations, with path coefficients of –0.420 (SWBS) and –0.256 (EWBS), both P < 0.001. Taken together, these results indicate that higher intolerance of uncertainty was associated with lower well-being; conversely, greater tolerance of uncertainty (TU) was positively associated with both subjective and eudaimonic aspects of well-being. Thematic analysis of free-text responses revealed four themes: (1) Positive recognition of uncertainty, (2) Acceptance of uncertainty, (3) Coping strategies, and (4) Growth through uncertainty.

Conclusion

Higher tolerance of uncertainty is positively associated with both subjective and eudaimonic well-being among Japanese primary care physicians. These findings suggest that fostering TU may enhance psychological health and support professional development.

Primary care physicians routinely encounter clinical ambiguity, including incomplete information, multimorbidity, and unpredictable illness trajectories. In Japan, where expectations for accuracy, decisiveness, and low error tolerance remain strong within medical practice and education, such uncertainty may carry significant emotional and professional burden.^{1, 2} This raises a key question: how do physicians psychologically cope with unavoidable uncertainty, and what implications does this have for their well-being?

Tolerance of uncertainty (TU) refers to the degree to which individuals can remain engaged and function effectively in the presence of ambiguity, unpredictability, or limited information.^{3, 4} Physicians vary widely in TU: some manage uncertainty with flexibility, while others experience anxiety, avoidance, or impaired clinical decision-making. Low TU has been linked to burnout, psychological distress, reduced job satisfaction, and defensive medical behaviors such as overtesting or avoidance of shared decision-making.^5,6,7,8 In medical trainees, lower TU has also been associated with negative attitudes toward socially vulnerable populations.⁹ Thus, TU represents not only an individual psychological trait but also a factor that influences clinical reasoning, professionalism, and patient care.

Internationally, growing attention has been directed toward the relationship between TU and physician well-being. Evidence suggests that higher TU is associated with emotional resilience, job satisfaction, and adaptive coping, particularly in demanding contexts such as the COVID-19 pandemic.^10,11,12 Recent work has proposed that resilience, workplace climate, and mindfulness-based interventions may strengthen TU and concurrently support well-being.^13,14,15,16 Moreover, emerging scholarship links TU to moral distress and identity formation, highlighting that low TU may erode meaning, motivation, and professional fulfillment.^{10, 17}

Well-being itself is multifaceted and can be conceptualized across two domains: subjective well-being (SWB), which reflects affect balance and life satisfaction, and eudaimonic well-being (EWB), encompassing purpose, personal growth, and self-realization.¹⁸ Although TU has been examined in relation to burnout and stress, its association with both SWB and EWB—particularly in Japan—remains understudied.

Despite increasing global research, there is limited empirical evidence examining how TU relates to well-being among Japanese physicians, especially those in primary care who experience substantial diagnostic and relational uncertainty. To address this gap, the present study investigates the associations between TU and both SWB and EWB among Japanese primary care physicians. Additionally, qualitative analysis of free-text responses is used to explore how physicians perceive and make sense of uncertainty, with the goal of informing future educational and organizational approaches to supporting well-being in clinical practice.

In this study, we focused specifically on Japanese primary care physicians for several reasons. First, primary care clinicians are often the first point of contact for patients with undifferentiated symptoms, multimorbidity, and psychosocial problems, and therefore may be more frequently exposed to clinical uncertainty than organ-based specialists.¹⁹ Second, in Japan, primary care has been developing as a distinct field within a traditionally hospital- and specialty-oriented health-care system, and many physicians negotiate complex roles that span acute, chronic, and community-based care. These characteristics suggest that medical uncertainty is both frequent and consequential in the daily work of Japanese primary care physicians, making them a particularly important group in which to examine the relationship between tolerance of uncertainty and well-being.

SUBJECTS AND METHODS

Study design and participants

This study employed a cross-sectional observational design targeting primary care physicians practicing in Japan. Members of the Japan Primary Care Association (JPCA) frequently encounter clinical ambiguity, multimorbidity, and comprehensive patient care, which makes them an appropriate population to study tolerance of uncertainty and its potential psychological consequences. Data were collected over a one-month period, from March 1 to March 31, 2023, using an anonymous, self-administered online questionnaire. The survey link was distributed via the official mailing list of the JPCA, which includes 4,207 registered members at the time of distribution. Convenience sampling was used, and all members of the listserv who met the inclusion criteria were eligible to participate. The use of Google Forms enabled secure and anonymous data collection.

Inclusion and exclusion criteria

Eligible participants were physicians currently subscribed to the JPCA mailing list who provided informed consent and completed the survey. Individuals were excluded if they were medical students or postgraduate residents within their first two years of training, or if they failed to respond to any survey items. A total of 152 responses were received (response rate 3.6%). After excluding two cases with complete nonresponse, 150 valid responses were retained for analysis. Although the response rate was low (3.6%), it is comparable to previously reported response rates in web-based physician surveys addressing psychological or workplace factors.²⁰

Measures

Tolerance of uncertainty

The Japanese version of the Short Intolerance of Uncertainty Scale (SIUS)²¹ was used to assess individual differences in tolerance of uncertainty (TU). This scale comprises 12 items rated on a 5-point Likert scale (1 = not at all true to 5 = very true), and measures emotional responses and behavioral tendencies in uncertain situations. The Japanese version has demonstrated acceptable internal consistency (Cronbach’s α > 0.80) and construct validity in previous studies.²¹

Subjective well-being

Subjective well-being was assessed using the Subjective Well-Being Scale (SWBS), developed by Ito et al.²² This 15-item scale captures three components of subjective well-being: life satisfaction, positive affect, and negative affect (reverse scored). Each item is rated on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). The scale has shown good reliability in Japanese populations (Cronbach’s α > 0.80).

Eudaimonic well-being

The Japanese version of the Eudaimonic Well-Being Scale (EWBS)²³ was used to assess core dimensions of eudaimonic well-being, including self-realization, purpose in life, and personal growth. This instrument, developed based on Waterman’s conceptualization of eudaimonia as the fulfillment of one’s true potential and alignment with intrinsically valued goals, consists of 21 items rated on a 5-point Likert scale (0 = not true at all to 4 = very true).²⁴ The scale has demonstrated strong internal consistency (Cronbach’s α > 0.80) and factorial validity in prior validation studies with Japanese populations.

Free-text item (qualitative data)

To explore physicians’ subjective experiences and emotional responses to uncertain clinical situations, the following open-ended question was included at the end of the survey: “How does your emotional state change when you experience situations with high uncertainty?” Participants were encouraged to provide free-text responses based on their actual clinical experiences. These data were used to complement quantitative findings and provide insight into psychological adaptation processes.

Data analysis

Handling of missing data

For partially missing responses, multiple imputation (MI) was conducted using the fully conditional specification (FCS) method in SPSS Version 29. Missing values were imputed based on available demographic and scale data. The imputation model included age, gender, years since graduation, and all scale variables (SIUS, SWBS, EWBS). Five imputed datasets were generated, and pooled estimates were used for statistical inference. Two respondents with completely missing data were excluded.

Quantitative analysis

Descriptive statistics were calculated for all variables. Pearson’s correlation coefficients were computed to assess the relationships between TU (SIUS), subjective well-being (SWBS), and eudaimonic well-being (EWBS).

To further evaluate the hypothesized relationships, structural equation modeling (SEM) was conducted using AMOS 22. The SEM tested the direct paths from SIUS to both SWBS and EWBS. Model fit was assessed using standard indices: Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). Acceptable fit was defined as CFI > 0.90, RMSEA < 0.08, and SRMR < 0.08. The structural equation model was specified based on the theoretical hypothesis that tolerance of uncertainty affects psychological well-being. Consistent with prior literature,^{18, 24} subjective well-being (SWBS) and eudaimonic well-being (EWBS) were treated as independent yet complementary constructs representing distinct dimensions of well-being. Therefore, both variables were modeled as separate outcome indicators of intolerance of uncertainty (SIUS).

Qualitative analysis

Free-text responses were analyzed using thematic analysis as outlined by Braun and Clarke.²⁵ The analysis followed six steps: familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Coding was initially conducted independently by the first author (YO) and the second author (DS), who reviewed the responses, generated codes, and identified preliminary themes through inductive analysis. The derived themes were then reviewed by other co-authors to enhance analytical validity through triangulation. This process allowed for multiple perspectives to be incorporated, thereby improving the credibility and trustworthiness of the findings. Themes were subsequently mapped to existing psychological constructs. The integration of qualitative and quantitative findings aimed to provide a more comprehensive understanding of how physicians experience and manage uncertainty.

Ethical considerations

This study was approved by the Ethics Review Board of Tottori University (Approval No. 22A145). Participation was voluntary, and informed consent was obtained via the online survey. No personal identifiers were collected, and all data were anonymized and used solely for research purposes.

RESULTS

Participants’ characteristics

Table 1 shows the demographic characteristics of the 150 participants. The most common age group was 40s (36.7%), followed by 30s (28.0%), 50s (19.3%), 60s and older (13.3%), and 20s (2.7%).

Table 1.  Characteristics of participants.

Characteristic		n (%)
Age
	20–29 years	4 (2.7)
	30–39 years	42 (28)
	40–49 years	55 (36.7)
	50–59 years	29 (19.3)
	≥ 60 years	20 (13.3)
Gender
	Female	43 (28.7)
	Male	104 (68.3)
	Other	3 (2.0)
Years since graduation
	1–2 years	0 (0.0)
	3–6 years	11 (7.3)
	7–9 years	24 (16.0)
	10–19 years	51 (34.0)
	20–29 years	33 (22.0)
	≥ 30 years	31 (20.7)
Workplace (medical institution)
	Hospital (≥ 300 beds)	39 (26.0)
	Hospital (100–299 beds)	25 (16.7)
	Hospital (< 99 beds)	16 (10.7)
	Clinic (with beds)	9 (6.0)
	Clinic (bedless)	59 (39.3)
	Other	2 (1.3)
Department currently working in
	General practice	89 (59.3)
	Internal medicine	45 (30.0)
	Other	16 (10.7)
Specialist certification
	Board-certified in Family Medicine (JPCA)	55 (36.7)
	Board-certified in General Practice (JMSB)	10 (6.7)
	Certified Primary Care Physician (JPCA)	48 (32.0)
	None	15 (10.0)
	Other specialty certification	22 (14.7)

n = 150. JMSB, Japan Medical Specialty Board; JPCA, Japan Primary Care Association.

In terms of gender, 68.3% were male, 28.7% female, and 2.0% other.

Years since graduation were most frequently 10–19 years (34.0%), followed by 20–29 years (22.0%) and over 30 years (20.7%).

The most common workplace was non-bed clinics (39.3%), followed by hospitals with over 300 beds (26.0%).

Regarding specialties, general medicine (59.3%) and internal medicine (30.0%) were most common.

Regarding certification, 36.7% were certified in family medicine, and 32.0% held JPCA certification.

Correlation analysis

The mean SIUS score was 29.4 (SD = 7.54), with scores ranging from 17 to 52. The mean SWBS and EWBS scores were 45.4 (SD = 6.13) and 55.5 (SD = 9.99), respectively (Table 2).

Table 2.  Descriptive statistics of SIUS, SWBS, and EWBS (n = 150).

Scale	Mean	SD	Range
SIUS total score	29.4	7.54	17–52
SWBS total score	45.4	6.13	23–60
EWBS total score	55.5	9.99	25–80

Higher SIUS scores indicate greater intolerance of uncertainty. EWBS, Eudaimonic Well-Being Scale; SIUS, Short Intolerance of Uncertainty Scale; SWBS, Subjective Well-Being Scale.

Pearson’s correlation analysis showed that SIUS was significantly and negatively correlated with SWBS (r = –0.433, P < 0.001) and EWBS (r = –0.259, P = 0.001). This indicates that physicians who reported greater intolerance of uncertainty tended to report lower levels of both subjective and eudaimonic well-being.

SIUS scores were negatively correlated with both SWBS and EWBS.

Structural equation modeling

Structural equation modeling (SEM) revealed that intolerance of uncertainty, as measured by the SIUS, had a significant negative effect on both subjective well-being (SWBS) and eudaimonic well-being (EWBS). As illustrated in Fig. 1, the standardized path coefficient from SIUS to SWBS was –0.42 (P < 0.01), indicating a moderate inverse relationship. Similarly, the path from SIUS to EWBS yielded a coefficient of –0.26 (P < 0.01), suggesting a weaker but still statistically significant negative association. Model fit indices indicated an acceptable fit to the data, with a Comparative Fit Index (CFI) of 0.92, a Root Mean Square Error of Approximation (RMSEA) of 0.06, and a Standardized Root Mean Square Residual (SRMR) of 0.05.

Fig. 1.

 Structural equation model of the relationship between intolerance of uncertainty and well-being. This figure illustrates the structural equation model (SEM) examining the effects of intolerance of uncertainty (as measured by the SIUS) on subjective well-being (SWBS) and eudaimonic well-being (EWBS). Standardized path coefficients are shown along the arrows. Intolerance of uncertainty had a significant negative effect on SWBS (β = –0.42, P < 0.01) and EWBS (β = –0.26, P < 0.01). Latent variables are represented by ellipses, and observed indicators by rectangles. **P < 0.01. SWBS and EWBS were modeled as distinct outcome variables to reflect their theoretical role as independent but complementary dimensions of well-being.

Thematic analysis

Thematic analysis of the free-text responses to the question “How does your state of mind change when you experience a highly uncertain situation?” identified four main categories (Table 3).

Table 3.  Themes identified from physicians’ responses to uncertainty.

Category	Theme
Positive recognition of uncertainty	Viewing uncertainty as a constant element in clinical practice
	Recognizing the positive aspects of uncertainty
	Embracing uncertainty as part of the role of a family or general physician
Acceptance of uncertainty	Adopting a mindset of acceptance and resignation—trusting that things will work out
	Focusing on doing what can be done in the present moment
Coping strategies for uncertainty	Responding calmly and thoroughly to uncertain situations
	Taking breaks and shifting perspectives during difficult moments
	Facing uncertainty through collaboration with colleagues
Uncertainty as a catalyst for challenge and growth	Viewing uncertainty as a worthwhile challenge
	Perceiving uncertainty as an opportunity for personal growth

Positive recognition of uncertainty

Physicians viewed uncertainty as an essential and even enriching aspect of clinical practice. Some acknowledged that uncertainty is always present, while others saw it as deepening their engagement with care.

Acceptance of uncertainty

Respondents expressed acceptance of uncertainty as inevitable. Phrases like “doing what I can now” and “what happens, happens” indicated a pragmatic, composed stance, likely serving as an emotional coping strategy.

Coping strategies for uncertainty

This theme involved concrete actions to manage uncertainty, such as pausing during difficult situations or consulting colleagues. These behavioral strategies reflect self-regulation and resilience.

Uncertainty as a catalyst for growth

Some physicians saw uncertainty as an opportunity for personal growth or challenge, saying they felt motivated or found such situations rewarding. This mindset may be linked to higher well-being.

DISCUSSION

This study investigated the association between physicians’ tolerance of uncertainty (TU) and two dimensions of well-being—subjective well-being (SWB) and eudaimonic well-being (EWB)—among Japanese primary care physicians. The findings demonstrated a moderate positive association between TU and both types of well-being, indicating that physicians who are more able to cope with uncertainty tend to report higher emotional satisfaction and stronger psychological meaning in life. These associations were consistent across correlational analysis and structural equation modeling, supporting the robustness of the observed relationship.

Including both SWB and EWB provided a multidimensional understanding of physician well-being beyond burnout, stress, or job satisfaction, which have dominated previous research.^{26, 27} Whereas SWB reflects hedonic aspects such as affect balance and life satisfaction,²⁸ EWB reflects meaning, purpose, autonomy, and personal growth.¹⁸ The association between higher TU and higher EWB may suggest that the capacity to engage constructively with ambiguity supports deeper aspects of professional fulfillment. However, due to the cross-sectional design, alternative interpretations remain possible—for instance, physicians with higher well-being may be more capable of tolerating uncertainty.¹³

Qualitative findings enriched these quantitative results by illustrating how physicians experience and respond to uncertainty. Responses ranged from discomfort and resignation to acceptance, adaptive coping, and growth-oriented engagement, aligning with conceptualizations of variation in emotional and professional responses to uncertainty.^{29, 30} These findings support the perspective that TU is shaped not only by dispositional traits but also by environmental, cultural, and experiential factors. It is important to note that tolerance of uncertainty does not imply disengagement or avoidance. Rather, it reflects the ability to remain psychologically engaged with uncertainty without excessive emotional distress.

Taken together, the results suggest that TU may represent a potentially modifiable factor relevant to well-being in clinical practice. Previous studies indicate that reflective discussion, mentorship, and training that normalizes ambiguity can enhance learners’ comfort with uncertainty.^{14, 31, 32} Additionally, interventions such as mindfulness, cognitive reframing, and resilience training have been shown to contribute to psychological well-being among healthcare professionals.^{33, 34} In this context, TU may serve as an important component within broader frameworks of resilience, clinical reasoning under complexity, and professional identity formation in primary care.^{19, 26, 29} However, given the design and scope of this study, these interpretations should be regarded as exploratory.

Future research employing longitudinal or interventional designs will be necessary to determine whether enhancing TU can meaningfully improve psychological well-being, or whether well-being itself facilitates the development of uncertainty tolerance. Mixed-methods and comparative studies may also help clarify contextual influences—including workplace culture, attitudes toward error, and educational norms—that shape how uncertainty is perceived, communicated, and managed within Japanese medical settings.^{1, 35,36,37}

Several limitations should be acknowledged when interpreting the results of this study. First, the response rate of this study was low (3.6%). This low participation level, combined with the sampling approach, may limit the representativeness of the findings. Because participants were recruited through the mailing list of the JPCA, respondents may not reflect the full diversity of Japanese primary care physicians. It is also possible that those who chose to participate had greater interest in well-being or uncertainty, introducing potential non-response and self-selection bias. Moreover, the majority of respondents were in their 30s and 40s with more than 10 years of clinical experience, whereas early-career physicians were underrepresented. Younger doctors, who may experience greater stress or lower tolerance toward uncertainty, were thus less reflected in the data. Future studies should include more early-career participants to explore how TU develops throughout different stages of clinical training. Therefore, caution is required when generalizing these results to all Japanese physicians. Second, the cross-sectional design limits our ability to infer causal relationships between tolerance of uncertainty (TU) and well-being. While the observed associations were statistically significant and theoretically consistent with prior research, longitudinal studies are needed to determine whether changes in TU precede or follow changes in psychological well-being. Third, all measures were based on self-report questionnaires, which may be subject to social desirability bias or inaccuracies in self-perception. Participants may have underreported negative emotional states or overestimated their coping abilities in uncertain situations. Fourth, while the study included a free-text qualitative item, the depth of qualitative data was inherently constrained by the survey format. In-depth interviews or focus groups would likely yield richer insights into how physicians experience and navigate clinical uncertainty in practice.

In conclusion, this study demonstrated that lower tolerance of uncertainty among Japanese primary care physicians is associated with reduced subjective and eudaimonic well-being. Physicians who accepted or positively engaged with uncertainty reported higher psychological well-being, suggesting that TU is not merely a trait but a modifiable factor influenced by mindset and context. These findings underscore the importance of developing TU through individual, educational, and organizational strategies. Future research should focus on intervention design, longitudinal outcomes, and behavioral impacts to better support physician well-being and patient care quality.