Uncertainty in Medical Providers – PediaCast CME 100

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Description

  • Drs Alex Rakowsky, Claire Stewart, Anna Kerr, and Charee Thompson visit the studio as we consider uncertainty in medical providers. Uncertainty may appear troubling at first glance, but recognizing and managing uncertainty leads to professional growth and improved outcomes. Tune in to learn more!

Instructions to obtain CME/CE Credit

  1. Read this information page.
  2. Listen to the podcast.
  3. Complete the post-test at Nationwide Children’s CloudCME.

Topic

  • Uncertainty in Medical Providers

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Learning Objectives

At the end of this activity, participants should be able to:

  1. Provide a definition of “medical uncertainty” and the types encountered in clinical practice.
  2. Name some ways that poor management of medical uncertainty can lower the quality of medical care.
  3. Name several ways medical uncertainty can be used as a learning tool, allowing providers more insight into their gaps and how to address them.
  4. Identify ways to work with colleagues to address issues of medical uncertainty unique to their clinical setting.

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Disclosure Statement

No one in a position to control content has any relationships with commercial interests.

Commercial Support

Nationwide Children’s has not received any commercial support for this activity.

CME/CE Information

  • In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
  • Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
  • As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
  • Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Contact Us

  • CMEOffice@nationwidechildrens.org

 

Episode Transcript

Dr Mike Patrick: This episode of PediaCast CME is brought to you by Primary Care Pediatrics and Critical Care Pediatrics at Nationwide Children's Hospital.

Hello everyone, and welcome once again to PediaCast CME. It is a continuing medical education podcast for healthcare providers. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It is episode 100. We're calling this one uncertainty in medical providers.

We want to welcome all of you to the program. So, episode 100 is definitely a milestone and I think that this Particular topic is really appropriate as we celebrate 100 episodes because there is uncertainty in medical providers and it becomes difficult really because when you think about something like the game of baseball, all right a hitter is considered super talented If they can maintain a batting average of three 33.

Now that means they hit the ball and make it the first base once in every three times at bat. But it also means they miss getting a hit and making it to base two thirds of the time. And again, that is considered really good. TV weatherman may achieve similar success rates, although maybe improving because of modern technology, but that's always been kind of a running joke that people make.

You know, they don't have to be right all the time, and that's fine for their jobs. But with medical providers, we are expected to hit the ball out of the ballpark and correctly forecast the weather 100 percent of the time. And it would seem that there is no room for uncertainty in the practice of medicine.

However, that is not really true. Uncertainty in medicine exists. And rather than pretending it doesn't exist, recognizing the uncertainty, leaning into it and looking for answers to questions that have us stumped. These situations provide us opportunity to learn and grow and improve patient outcomes. So today we're going to explore uncertainty in medical providers, uh, from medical students to residents, to attending physicians.

And in particular for attending physicians and professors, it's really important that we are transparent when we have uncertainty because our learners are looking up to us and they're watching how we deal with uncertainty in our practice. So, we're going to explore all of that today. And of course, in our usual PediaCast CME fashion, we have some terrific guests joining us.

Dr. Anna Kerr is with health communications at Ohio university. Dr. Sheree Thompson, also an expert in health communications at the University of Illinois. Dr. Claire Stewart with critical care pediatrics at Nationwide Children's Hospital. And our conversation this week will be led by Dr. Alex Rakowski.

He's with primary care pediatrics at Nationwide Children's. After listening to this episode, be sure to claim your free category one credit. It is really easy to do. Simply head over to the show notes for this episode at PediaCastCME. org You'll find a link to the post test in the show notes, follow that link to cloud CME, click on the materials tab, taken past the posttest and the category one credit is yours really easy.

And we do offer credit to many pediatric professionals, including doctors, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since nationwide children's is jointly accredited by many professional organizations, it’s likely we offer the exact credits you need to fulfill your state's continuing medical education requirements.

Of course, you want to be sure the content of this episode matches your scope of practice, which really, as we think about uncertainty and medical providers, should be everybody. Complete details are available at PediaCastCME. org. Also want to remind you the information presented in every episode of our podcast is for general educational purposes only.

We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at PediaCastCME. org. So let's take a quick break. We'll get our expert panel settled into the studio, and then we will be back to talk about uncertainty in medical providers.

It's coming up right after this.

Dr. Anna Kerr is a health communications expert and an assistant professor at the Heritage College of Osteopathic Medicine at Ohio University. Dr. Charee Thompson is also an expert in health communications and an associate professor at the University of Illinois Urbana Champaign. Dr. Claire Stewart is a critical care physician at Nationwide Children's Hospital.

And an associate professor of pediatrics at the Ohio State University College of Medicine. They each have a passion for recognizing and managing uncertainty in medical providers, including the benefits in provider education and patient outcomes that accompany wellness. Uncertainty. Lots more to explore with that, but first let's give a warm PDA cast welcome to our guests.

Thank you so much for joining us today. Dr. Alex Rakowsky will be leading the conversation this week. You will recall that Alex is a primary care pediatrician at Nationwide Children's Hospital. He's also a member of our recurring pediatrics in plain language panel. If his voice sounds familiar to you, now you know why.

Alex, thanks for all your hard work preparing this episode for the audience. And with that, I will turn the reins over to Dr. Rakowski as we consider uncertainty and medical providers.

Dr Alex Rakowsky: All right. Thank you, Mike. And good morning, everyone. I know we went through introductions briefly, but if we can just go around.

And just like, in like one or two quick lines, tell me how your work relates to medical uncertainty. Charee let's start off with you.

Dr Charee Thompson: Hi, thanks Alex. I'm interested in how people navigate chronic illnesses in their relationships and in their families. I'm interested in what happens when people have uncertainty that can manifest as bias or sometimes when patients feel health dismissal and I'm also interested in creating trainings to help providers as well as patients manage uncertainty in their interactions with one another.

Okay, Claire.

Dr Claire Stewart: Yeah, so I got involved in the uncertainty work through my work with our pediatric residents. I'm one of the associate program directors of our pediatric residency program. And I think uncertainty is very pertinent to our medical trainees and how we can educate our medical trainees about uncertainty and communication with families.

Dr Alex Rakowsky: And then finally, Anna, and I'm also going to give you the task of defining what medical uncertainty is, once you're done, saying why you kind of got into the field to begin with.

Dr Anna Kerr: Thank you. So, broadly, my research focuses on patients navigating rare disease care. So not only how patients and families manage uncertainty, but how their clinicians and healthcare teams manage uncertainty also.

So broadly, medical uncertainty is experienced in a lot of different facets of healthcare, but when we speak about it broadly, it's kind of this actual or perceived inability to determine the cause of a patient's symptoms, to diagnose, to understand the prognosis, or even the best course of treatment.

Dr Alex Rakowsky: So, uncertainty is a sort of wide topic.

So, as it relates to medical uncertainty, Charee, is there any like breakdown of types of uncertainty that you can kind of put this into to kind of make it easier to understand for our listeners?

Dr Charee Thompson: Yeah, absolutely. Let me make it a little more concrete because I think once you can sort of diagnose the type of uncertainty you have, you can better address it if you know where it stems from.

So, the first type is technical uncertainty. We also call those data related uncertainty. Uncertainty. So, this is when a clinician might lack knowledge or skills. So, they may lack knowledge from insufficient information or data. You know, via the medical history, exams, et cetera. Physicians may also lack skills or confidence in their skills.

They may know how to do something, but not have the confidence to do so. Um, so that's technical uncertainty. The second type is personal uncertainty. We also call this relationship related uncertainty. So, this is when a physician might not know what a patient or family's wishes, values, or expectations are.

And then finally, the third type is conceptual uncertainty. And so, we also call this application related uncertainty. So, this typically happens when we're unable to apply concrete criteria. Perhaps we have all the knowledge and the skills, but when rubber meets the road. We're unable to apply it or know if it applies in this situation.

Dr Alex Rakowsky: So, Claire, in your field, ICU uncertainty, you know, can be dangerous, let's be honest. So, can you give examples that you've seen in your career? Let's start off with the easy one. Technical.

Dr Claire Stewart: So, I think I agree with you. I think technical uncertainty is kind of the easiest one to understand. So, I think about it as.

You know, a certain procedure that we may have to do on a child. So, for example, lumbar puncture, lumbar puncture is a procedure that a lot of our pediatric residents do regularly, but when they first start as interns, they may be uncertain that they have the skills that are needed to, to do that procedure.

The next type of uncertainty that Sheree mentioned was personal uncertainty, and that's when you are not sure about what a patient is. What a family desires what their wishes are. So, the way I relate this one, especially in my own world in the pediatric intensive care unit is for patients that may be at the end of their life.

What treatments of family is interested in still pursuing? What do they feel like will add quality of life to their child and also to their, you know, to their own lives. And then the last one that you know that we deal with quite a bit is, is that diagnostic uncertainty. So And this is the one I think that when we talk about uncertainty is the one that people think about the most in that what, you know, a certain patient is not fitting into a certain illness script or a patient does not seem they may have a constellation of symptoms that a provider has not seen before or, you know, they have asked lots of consultants.

To help and the consultants aren't sure what's going on. So, this is the one that I think can be the most difficult for our trainees to, to deal with.

Dr Alex Rakowsky: And also, as a clinician, I want to throw in a couple examples also. So, for example, for personal uncertainty, we really try to do a lot of shared decision making, but if you don't really understand where the patient and the family are coming from, then it's kind of hard to kind of move forward with the shared decision making and, you know, we have more life and death.

I have more of a, you know, primary care focus, but I feel that that's one that we tend to not really think about, but really makes relationships with patients so much easier. And, and I agree with the, with the conceptual, I think a lot of trainees struggle. With the lack of experience to take like an AAP guideline and then throw it into an individual patient or massage it into taking care of an individual patient, because none of our patients hit the script, let's be honest, nobody follows a textbook, and that's why it's fun to be a doc, because you keep on learning things, you know, 35 years out.

All right, Claire, since I have you on, let's start off some, how can uncertainty harm a patient? So, we're going to talk about the harm of uncertainties. It sounds common. So, let's start off with the negative and we'll end with the positive. So, patient level, how does uncertainty harm?

Dr Claire Stewart: Yeah, so uncertainty. You know, you could say that, you know, if a, if a clinician is uncertain and they do, they just do all of the tests and so they're not going to miss anything.

And in abstract, that seems like it wouldn't necessarily harm a patient, but it actually, it actually can do harm. So, you know, that might mean more blood draws for a child. That may mean, you know, draw a child doesn't have a lot of blood. So, drawing more blood can harm a child that also increases the cost of medical care.

It may cause a clinician to refer to a subspecialist more often, which then takes up that subspecialist time for other children that that may need that subspecialist. Again, there's a cost associated with that. Clinicians that are more uncomfortable with uncertainty may be more reluctant to withdraw withdrawal intensive therapy.

You know, there may be a family that feels like their child has reached the end of their life, and the clinician is less willing to meet that family where they are if they're not comfortable with the uncertainty. The other side of that is that If a clinician doesn't like that feeling of uncertainty, they may be more likely to have a premature closure or to miss a diagnosis because they don't want to think about the uncertain parts of the patient's diagnosis, and they just want to look at one part of the diagnosis and say, Okay, they have this, even though they may be ignoring other signs or symptoms and can that can lead to a misdiagnosis.

Dr Alex Rakowsky: So, Anna, we all work in teams. So how does uncertainty hurt the dynamic of a team?

Dr Anna Kerr: They really relate to these facets that Claire just discussed of that when they don't openly discuss uncertainty in healthcare teams, it can be detrimental to the patient's care. So, it can result in medical errors during a patient handoff, for example.

Or premature incorrect diagnoses, and so discussing uncertainty can really improve interprofessional collaboration, which can improve that diagnosis process and that clinical reasoning process. And when it comes to a healthcare team, we often see clinicians struggle with uncertainty the most when they're making decisions that are at the limits of their knowledge.

And so, reaching out to a senior physician or a specialist in a different field can be beneficial if it fosters a conversation where multiple possible answers are discussed. Or you point to some of those premature diagnoses you might be making when you're not thinking of all of the. possible alternatives or other evidence that might be there when making that diagnosis.

Dr Alex Rakowsky: So, Charee, we discussed how it impacts a patient and family, how it impacts a team. How about at the individual provider or researcher level? How does, how does uncertainty do harm?

Dr Charee Thompson: Yeah, thanks for that question, Alex. I think it's important to acknowledge that in the, in the short term, in the moment, it's normal for physicians who are experiencing uncertainty to be uncomfortable, to be a little stressed, to worry.

I think it becomes more distressful and kind of problematic and harmful when that feeling persists or it leads to some of these actions that, that Claire and Anna talked about. There are some studies that show that in pediatric residents that higher levels of stress due to uncertainty, so it's not the uncertainty itself, it's the stress from it and how people think about it is negative.

It's linked to lower resilience amongst the residents as well as depressive symptoms and burnout. So, I mean, this might be a chicken and egg kind of thing, but the fact that an inability to cope with uncertainty in productive ways is associated with these other sort of harmful outcomes that we have a pulse on in medicine, right? Like burnout.

Dr Alex Rakowsky: So, old sports adages, no pain, no gain. I think that's also the case in medicine. You'll learn from being a little stressed out. There's like a lot of medical education studies that have looked at the fact that having a little bit of grit in your development. Both as a trainee and further on as a faculty member or a practicing clinician outside of an academic center helps you kind of keep pushing yourself.

So, let's go to the positive here. So, thoughts, Anna, on how uncertainty can actually be beneficial for all of us, either as providers or researchers.

Dr Anna Kerr: Yeah, you pointed to this is that it really, if we shift the mindset that uncertainty is not inherently negative, but it can actually be used as an opportunity for innovation, scientific discovery, curiosity, then it can improve patient safety and clinical reasoning when it's discussed openly that there's a lot of room for growth and we hear often from residents that they really value that conversation with an attending where everyone can be honest about what they're uncertain about.

We can really kind of admit that medicine has limits to knowledge and that there's things that we just don't know as society. And so, when we kind of narrowly pursue certainty, it makes this assumption that there's one right answer. And I think all of us would agree that when you frame it as there might be multiple answers and we promote curiosity, that it really can improve patient care, can reduce some of those feelings of burnout, of needing that one right answer.

And then it also can translate to increased trust with patients and families when you bring them into that shared decision-making process and normalize uncertainty for them, and that you're a trusted partner in managing that uncertainty.

Dr Alex Rakowsky: So, so Claire, your work of medical students, residents, and fellows and faculty, can you give an example or two of how uncertainty has led to better development, I'll vape provider and you can pick any of the levels or give examples from a few if you want.

Dr Claire Stewart: Yeah. So, I think, you know, that uncertainty and conveying uncertainty to a family really allows us to have a better therapeutic relationship with a family and really allows us to show empathy and compassion to the families. So, you know, I think, and I'll, we'll kind of talk about this in a little bit, but we are, we are so ingrained as, trainees that we need to have all of the answers and that we need to always, you know, that there's always one concrete answer.

That's the nature of taking a test is that there's one concrete answer. And I, you know, I think it's a delicate balance. I think shared decision making is a really delicate, delicate balance because we don't want to put too much of a burden on a family, right? Because a lot of our families are, do not have a medical background.

And so, it's important to, to both. Be able to make some decisions, but then also tell the family why you're making a certain decision or why you're uncertain about something. I'll give an example. I recently had a patient who had what's called a febrile seizure. So, they had a seizure associated with a fever, which are very common in young Children.

But this child had a seizure that lasted for a longer time, ended up with a breathing tube in the I. C. U. Now there's A few ways that we could go to work up why that happened, and one of them would include like a lumbar puncture and more diagnostic testing, and another one would include kind of watchful waiting and seeing how the patient did when she woke up from her seizure and her seizure medicines.

So, I had this conversation with the trainee and with the family about, you know, what, what, what are these two kinds of paths that we could take? Because we were uncertain what exactly the diagnosis was. And the family, I think, really appreciated that honesty, and we all kind of came to a decision of what, what diagnostic path or what treatment path we would take.

And I remember afterwards, a trainee really saying to me, you know, that was really helpful to, to be able, we can always do more, we can always do more tests. But what is the right thing to do for the child and the family I think is the most important thing and I think it's really important for our trainees to see us having those conversations.

Dr Alex Rakowsky: I'm going to give an example also from primary care because I agree shared decision making is a balance, but sometimes having a little bit of uncertainty kind of pushes you to do things better. So, we have a large number like many cities of Ghani refugees and a lot of the babies who are born here. are given for cultural and religious reasons like a black liner around their eyes.

And um, we were noticing at the Olentangy clinic that we had around 10 kids with elevated lead levels at their routine one-year visits. So, this is a year after birth. And then we started doing lead levels in some younger kids because we're starting to wonder why we're seeing this, not a blip, but like a trend towards high lead levels.

And honestly, I remember one of the residents who's now actually in attending asking what's going on here, and I was uncertain. There are your classic reasons for having a high lead level, and we told the parents, you know, are you using a mug from Afghanistan, or are you using anything decorative, etc. And it took some digging around and getting toxicology involved to start looking at body paints, and a lot of the body paints from Afghanistan use lead to make them a little easier to put on an infant's eye just because it's a moving target so you want something that you can quickly see.

Kind of paste on but it was the reaching out the toxicology that actually was stumped also because I haven't seen many of Ghani refugees until Recently we figured out it was the eyeliner and there was a discussion with the parents It took us a while to find out why this is going on But this is what's going on and we kind of brought it to a halt because the local stores started selling it's called coal On the KOHL, not the target kind of like store, but like it's the name of the actual paint.

Um, some local stores started selling lead free coal. Um, but it took about a year of being really uncertain of trying to figure this out, and it pushed all of us. I mean, I'll be honest, it really unnerved me not to know why this was going on, and it unnerved the families not to know why it's going on, but it was like this Mutual hunt.

We all play Sherlock Holmes, and we end up finding a cause. Toxicology has a lot to do with that, but, you know, but again, it was, I'm an older guy and the uncertainty of just like, I need to find out what's going on, I have no idea. And lead's not good in one's brain. So, just another example. Okay, so we talked about uncertainty, the harms it can cause, that it can definitely lead to growth, so we, we all do education, so can you develop a curriculum to kind of work on this, whereas uncertainty is so personal, that it's really hard to generalize it to a curriculum, so.

Sheree, let me start with you.

Dr Charee Thompson: Yeah, absolutely. And I think that's exactly what our team, the folks here on this call have been working on for the last couple of years, how to pair communication expertise with clinical expertise to develop a curriculum to help physicians and physicians in training, one, identify their uncertainty, because I said earlier, if you can sort of diagnose it, you can better address it.

If you have technical uncertainty, then training and education might be needed, right? You need more data. Yeah. Or if it's personal uncertainty, can we teach you skills on how to learn patient's wishes, engage in shared decision making? And then for conceptual uncertainty, perhaps you need to practice more.

So, we're colleagues if you're having difficulties applying sort of your knowledge. So, the, our first goal with a curriculum is, you know, what is the uncertainty and how do you manage it? And then two, I think, you know, communication is a science, and so we have tools that we can teach that are evidence based and how you can better communicate, because research tells us over and over that withholding uncertainty or suppressing it is harmful.

And so, the question is not whether you communicate it with patients, families, and attendings, at least from a resident's perspective, but how you communicate it. And we know, just as a quick tip, that You can express uncertainty, but then you need to say, what are we doing about it? Right. As you just can't say, I don't know, that's not reassuring at all.

So, and then our target audience, you know, over the course of the years, it's evolved and we realized, and it makes good sense that physicians at all levels of their careers, our target audience, as you mentioned, you know, even physicians who are really experienced encounter complicated cases, rare diseases, and even just keeping up on late latest medical data and research.

It's a lot, right? And then obviously physicians and training. Are an obvious target and Anna and I have been working with medical students now.

Dr Alex Rakowsky: So, Anna, I remember the first time you wrote to Claire and me, I was an APD at that time. You said, “Hi, I'm an uncertainty researcher and would you like to join my study with the residents?” And so, you've been doing this for some time. So, 10 years down the road, what has Dr. Kerr kind of done with her research and where has it progressed?

Dr Anna Kerr: So, like I mentioned earlier, so much of this is rooted in the work that I do with families navigating rare disease. And too much of what you and Claire were saying is I hear often that the families are getting passed physician to physician.

They're getting numerous incorrect diagnoses that were because. Someone didn't just say, I don't know, but let's do some research. Let me talk to people. Let me think about this. Or it was people saying, I don't know. And so, I don't want to be the person caring for you. And so, I'm not willing to take this case on.

And so, so much of what I've done is shifted into what are the examples of the people that are doing it right? And it's the primary care doctor who says, I was driving home, and I heard this podcast and they mentioned this and let me call this person and let me do this. And so, it's looking at these ways to foster a culture where we're not going to eliminate uncertainty in medicine.

In fact, it's going to keep growing. As we have more genetic advances and scientific advances. And so, my focus has been on ways to improve communication between doctors and patients, but also between doctors across healthcare systems. Because we have families in rural areas whose specialist is in Boston, and they need their primary care physician to be able to manage and tolerate uncertainty with them at home and have these conversations.

And so, working on things like how do we implement communication tools into electronic health records? So that we can have communication in that sense. And how do we foster improved interdisciplinary collaboration in this sense? And so, it's really moved to how do we have people that are willing to say, I don't know, and that that's not a threat to your competence as a physician, but it's a way for you to partner with a patient and a family.

And work with them as they navigate these sometimes-lifelong journeys with rare diseases.

Dr Alex Rakowsky: So, so Claire, from the perspective of a clinical educator, some, let's say, more concrete examples in the next couple years of how you like to get either lectures or some kind of curriculum into Let's start off with your fellow since you probably have a lot more input in like moving the ship of the fellowship lectures for the PICU.

Dr Claire Stewart: Yeah, I think, you know, the, the, the root of this really starts even earlier, right? It's really starts, as Anna and Charee mentioned, in medical school. So, You know, I think we, we are never taught about uncertainty in medical school or we haven't historically been, you know, you're judged as I kind of mentioned earlier by how much, you know, your concrete answers, you take tests, you take board exams, there's one right answer and, you know, even medical students get asked questions on, on rounds and, and they need to have an answer and they're judged by, by what their answers are.

And so, I think we really have to start, you know, early. We really have to start from medical students. And so, by the time our trainees get to fellowship that they are comfortable with, you know, with uncertainty and with modeling that uncertainty. And I, I feel like I've been asked by, you know, medical students and they'll ask me a question and I won't know the answer to it.

Maybe I just never learned it, or I haven't learned it in several years or I, or there's no right, right or wrong answer, you know, and they'll have read something in a textbook, and you'll have something that's very different. And so. You know, being able to say, and sometimes they're surprised. I think when you say, well, I don't know, because it feels like, you know, at this point, I've been, you know, a faculty member for almost eight years, and it feels like I should know those things.

And I think I think medical students are always surprised when you say, I don't know. But We do see that, you know, on the fellow level that we see fellows that really struggle with things are either black or white, and it's they really struggle with how to translate the book knowledge and the things that they're reading in the textbook to the patient in front of them, because, as you mentioned, Alex, that most times are our patients don't follow the textbook.

And so, you know, this, having this curriculum and, and having the ability to help our trainees is, is really essential at all levels.

Dr Alex Rakowsky: Yeah. All set. All right, Anna. So, let's jump into ongoing projects. So, I'm going to combine a couple of questions here. So ongoing projects. And if you can give a brief update of what's been found, at least on them, like a brief, like, overview.

Dr Anna Kerr: Yeah. So, the team on this call that's been doing amazing work since whenever that was many years ago, and I reached out to you all and said, hey, do you have any interest in this has really kind of had two arms. So, we've had projects that are focused on residents and doing a longitudinal study of over the course of residency.

What are the goals and challenges they feel when communicating about uncertainty? And as healthcare communication researchers, Sheree and I really had that interest in it. We can't shift the level of uncertainty they have often, but we can shift how they respond to it and how they manage it. And so that's why in that study, we really focused on the goals and challenges they face when they communicate about uncertainty with faculty and with patients.

And we really found that they're navigating these multiple goals all at one time, right? I want to seem competent, but I need to accomplish the purpose of the visit, right? I need to give a diagnosis, or I need to make sure I close with a plan of action for the patient. And then they also have these relational goals of I want them to have a good relationship and come back to me, and I want my attending to feel like they can come to me in the future with responsibility.

And so, our goal, no pun intended, of our research has really been to demonstrate that these are conversations that you have to attend to multiple things. And so how do we integrate that into a curriculum? And so that's what we did. We developed a curriculum where we talked to them about attending to multiple goals in these conversations.

And we're analyzing pilot data from that right now, but it was an overwhelmingly positive response. I think it was, A, it normalizes that these are challenging conversations, but they should happen. To Claire's point, like, it was like, I just love it when my attending will just admit that they have uncertainty, and everyone's just open and honest about it, and we're not giving this so much credit.

illusion that there's boundaries around this case. And then we also received funding from the American Association of Colleges of Osteopathic Medicine to survey faculty about their perceptions about communication with residents. Because it's not a one-sided thing, right? It's the mentoring relationship.

And it's something that needs to be modeled by attendings as well. And so, in that study, we've really looked at how the conversation should happen and what attendings prefer and the difficulty that they face themselves and having those conversations and admitting their own uncertainty.

Dr Alex Rakowsky: Now you had mentioned, Claire had mentioned about medical student level also.

So, Charee, thoughts about going to the medical student level with uncertainty?

Dr Charee Thompson: Yeah.

Dr Alex Rakowsky: Curriculum.

Dr Charee Thompson: Yeah, absolutely. And I've been working on revising the curriculum that we've created for medical students. And overall taking the training and modifying and adapting it for different things. stakeholders, audiences, and also different specialties.

And I think our goal overall is to ensure that across their career, they have physicians of physicians training, cat support, right? Like you said, physicians who have been out for a long time still experience uncertainty. Maybe they want to improve. They probably do. They can. I think we also want to address attendings of medical students so that we can shift overall a culture of medicine where across the career, people feel more comfortable talking to each other about uncertainty because our findings tell us that over time, residents become more confident talking about uncertainty with patients, but not necessarily attending.

So, what is happening are that they're perhaps afraid to bring it up. They don't want, as Anna said, they don't want to look incompetent. So, we have to help attendings realize that they're modeling this. And how can they be sort of safe, comfortable spaces where residents can say, I don't know, without fear of punishment, et cetera.

And I think overall, if we can across, you know, medical school through residency, and beyond strengthen interprofessional relationships among physicians and learners and mentees and mentors. And we can help physicians with their own professional well-being in their relationships with one another and ultimately patient care.

Dr Alex Rakowsky: I'd like to thank everybody and let me just kind of do like a real quick any last comments that you would like to say sort of a few Claire.

Dr Claire Stewart: Yeah, I think, you know, we talk a lot about burnout in medicine. These days, and I think it's a very important topic, but I think one way that has been shown to decrease burnout is relationships with families and the, you know, building therapeutic reliance’s with families, and that's also been shown to improve the patient experience.

And so, I think. You know, this work is so important to help build therapeutic alliances with families and really allow us to get more satisfaction from our work, and then also to give patients and families better care and more satisfaction. So, I think, you know, we talk about uncertainty in an abstract way, but I think those are really, really important.

Super important concrete ways that we can use our uncertainty work. Sure,

Dr Charee Thompson: like as a professor, I feel like as I would hope for physicians much like I do as a professor, I feel like I am happier in my job, and I feel like I have greater impact to those I serve and teach. When I become more comfortable admitting what I don't know right and being vulnerable And I think that's a better way to build relationships I actually feel more confident kind of in a paradoxical way being more humble about what I do know and what I don't know So I hope that that's what we're able to instill through our curriculum and what we teach You

Dr Anna Kerr: know one thing that stands out as we discuss this the curriculum is I think broadly our goal is to make this really Embedded within clinical practice and medical education and not necessarily just a one off training that you have as this As if it only applies to communication in this setting and so thinking of ways that we can integrate conversations about uncertainty at multiple points throughout undergraduate and graduate medical education and make it really a cultural shift and not just a checkbox that you did your training and now you know what to do because as You go through your education, your knowledge changes, and your confidence changes, and the autonomy that you have in practice changes.

And so, this is an evolving concept. Just as there's not one right answer, right, we are not going to, as communication researchers and professors, give you a script of how to talk about uncertainty. Because every patient is different, every scenario is different, how you feel about uncertainty is different than the person standing next to you.

And so, this is really about kind of building the muscle of how to do this often and feel confident in it more so than it being A checklist or a script that we can give that has, again, one right answer like we've talked about.

Dr Alex Rakowsky: So let me give a plug. So those interested, we have had several posters and a couple articles, more communication in health care journals, but there will be an article coming out in the Hospital of Pediatrics about some of our initial work.

We're not sure yet, but sometime this year or so. I think our target audience probably reads possible pediatrics more in the communication journals, but, you know, feel free to kind of keep an eye out for those things and we'll let Dr. Mike know when that comes out. So, Mike, on to you.

Dr Mike Patrick: Well, this has been a really fascinating conversation and so many of your points have really resonated with me.

And, uh, you know, working in the emergency department, we are confronted with unknowns a lot. And I think, again, just being honest with, with our students and, uh, letting them know, you know, we're human and there's a lot of things that we know, there's a lot of things we don't know. It's important to know the things we don't know and where we can find the answers that we need and the help, uh, like the, the toxicology example.

But so, I think this is really. Important work, and I'm definitely looking forward to seeing where all of this goes and to see the publications that arise out of it. We are going to have some links in the show notes over at PediaCastCME. org, and we will put, as more becomes available, we will add to that.

But right now, we do have an article from the New England Journal of Medicine, Tolerating Uncertainty. The next medical revolution, another one medical from medical teacher, 12 tips for thriving in the face of clinical uncertainty. And another one from JAMA, Journal of the American Medical Association, understanding and communicating uncertainty in achieving diagnostic excellence.

So, we will put all of those links in the show notes over at PediaCastCME. org. So if you want to take a little bit of a deeper dive, please do so. So once again, Dr. Anna Kerr with Health Communications at Ohio University, Dr. Sheree Thompson from the University of Illinois, Dr. Claire Stewart with Critical Care Pediatrics and the Ohio State University College of Medicine.

And of course, Alex, thank you so much for all your work getting this group together and coming up with the learning objectives and the interview questions and the posttest and all those things. So. Kudos to you. We really appreciate your efforts.

Dr Alex Rakowsky: No, thank you. So, colleagues, I have loved working on this topic.

It's one that I wasn't certain about doing an uncertainty study. I'll be honest with you, but it has opened some eyes and I have been very blessed to kind of work with you all. So, thank you.

Dr Claire Stewart: Thank you for having us. Yeah, thank you

Dr Mike Patrick: We are back with just enough time to say thanks once again, to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Anna Kerr with Ohio University, Dr. Charee Thompson with the University of Illinois, Dr. Claire Stewart with Critical Care Pediatrics at Nationwide Children's Hospital, and our guest host this week, Dr. Alex Rakowsky with Primary Care Pediatrics at Nationwide Children's. Don't forget, you can find us wherever podcasts are found. We're in the Apple and Google podcast apps. I heart radio, Spotify, SoundCloud, Amazon music, YouTube, and most other podcast apps for iOS and Android.

Our landing site is PediaCastCME. org. You will find our entire archive of programs there. Along with show notes for each of the episodes are CME information that terms of use agreement and our handy contact page. If you would like to suggest a future topic for the program, reviews are helpful wherever you get your podcasts.

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Really easy thing to do. Simply head over to the show notes for this episode at PediaCastCME. org. It's episode 100. You'll find a link to the post test in the show notes. Follow that link to cloud CME, click on the materials tab, taken past the posttest and the category one credit is yours. Super easy.

And again, we do offer credit to many pediatric professionals, including physicians, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. Of course, you want to be sure the content of the episode Matches your scope of practice. And again, this one really does apply to everybody.

Complete details are available at PediaCastCME. org. Also don't forget about our evidence pot. Also don't forget about our evidence-based podcasts for moms and dads. Lots of pediatricians and other medical providers also tune in as we cover pediatric news, answer listener questions and interview pediatric and parenting experts.

Shows are available at the landing site for that program, PediaCast. org. Thank you. Also available wherever podcasts are found, simply search for PediaCast. Thanks again for stopping by and until next time, this is Dr. Mike saying, stay informed, keep it evidence based and take care of those kids. So long, everybody.

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