|Uncertainty. We have all heard that word quite frequently lately. It tends to carry negative connotations and feelings of uneasiness. It seems the answer to every question these days is, “well, it depends”. As physiology educators, this is not new to us. How many times have we answered a student’s broad question with this same phrase? Regardless of how much active learning is accomplished in the classroom, students at all levels are tasked with preparing for and taking standardized tests. My children started taking assessments in preschool, multiple choice tests for grading purposes in kindergarten, and state assessment tests in 3rd grade. Then there will be standardized tests for admissions to college, graduate admissions, and licensing. It’s no wonder that some students are conditioned to study ‘to the test’ instead of having the goal of truly learning the material, and are hesitant to express when they don’t know something. I spent the first decade of my career teaching science at the undergraduate level and have spent the last five years teaching in the professional school setting, including medical, dental, and podiatry students. I have found that these health professions students in particular become especially aware of uncertainty when they start gaining experience with clinical cases and with patients. I also notice that they are uneasy with uncertainty even from the interactions in the classroom – they are high achieving students and don’t want to be wrong, to be perceived as not knowing an answer or a concept, of maybe feeling like they don’t belong. In truth, many students have the same questions, and the same feelings, but are hesitant to express them. It is known that dealing with uncertainty and ambiguity, especially in professions where people are serving patients whose health is at stake, can result in the experience of stress, anxiety, depression, and burnout (1). Wellness is an important consideration, especially in a climate where things seem to be changing day-to-day and we are provided limited information and answers. How one deals with uncertainty can lead to life and professional decisions including which career or specialty to pursue. While this concept is not novel, actually teaching students how to tolerate or even embrace uncertainty is a relatively new concept, one which I think should be made a more purposeful objective in our courses. What if instead of shying away from admitting we don’t know something, we learn how to accept it, and how to approach the problem to find the most effective answer? How do we best learn to tolerate uncertainty, and train our students how to cope with and learn from uncertainty? What are the benefits of embracing uncertainty? |
Bring uncertainty into the classroom Thoughtfully and purposely embedding uncertainty into activities in the classroom does several things. First, it allows students to learn that not every question has an absolute answer. Students need help shifting their mindset. This also encourages students to work with material at higher levels of Bloom’s taxonomy, like evaluation and application. Additionally, this helps create a culture in the classroom where asking questions and admitting to what we don’t know is a good thing, and brings value to classroom discussions. This allows students to bring in their own experiences in an attempt to work through a problem and arrive at an answer, enhancing students’ learning. Students can build their confidence as they find value in embracing the unknown as they learn to navigate the process to find the answers to their questions. The learning theory constructivism suggests that students build their own learning, that knowledge is built upon knowledge, and that it works best in context (2). This encourages students to bring their own experiences to the learning process, and the result is that each student may bring a different perspective and answer (3). These principles match well with the intention of teaching how to manage uncertainty. A goal is for students to be engaged and motivated in an active learning environment, allowing them to share ideas and build their knowledge based on their prior knowledge and experiences.
Leading to deeper learning To further expand the idea of students building their mental models, activities designed to allow for more open-ended thinking or answers, which build upon each other, can be utilized. For example, in the cardiovascular physiology component of our medical course, we build on the basic concepts in a series of small group sessions which encourage students to work in their teams to answer questions pertaining to these concepts. We may start with the principles of hemodynamics but eventually work our way to the integration of cardiac function and vascular function. These sessions require students to not only recall knowledge, but also apply information in a manner which may lead to uncertainty. They learn to question the severity of perturbations, the balance of factors which interact, and the cause and effect. We find students may become frustrated with the “it depends” answer, but they learn how to view the nuance and ask the appropriate questions. This type of exploration and learning transitions well to more clinical sessions, where students need to know which questions to ask, which tests to order, and which colleagues to consult.
Demonstrate uncertainty as educators and professionals In addition to our basic science session, I spend a lot of time teaching with clinical colleagues in the pre-clerkship medical classroom. We have a small cohort of core educators who participate in a special type of small group learning we call Clinical Reasoning Conferences. The core educators are either basic scientists or clinicians and come from different disciplines, bringing different experiences and expertise to each session. We are always joined by content experts in our sessions with the students as well. This means that we are likely to be in a session where we are not the content expert, but have immediate access to one. This gives us an opportunity to demonstrate uncertainty in the classroom, to students who feel constant pressure to know everything and to perform at the highest level. To be honest, it took a while for us to get comfortable with telling the students, “I don’t know”, but that “I don’t know” was, in reality, “I don’t know but let’s get the answer”, which gave us the opportunity to demonstrate how we get the answer. It could be a reference from the literature, a clinical resource, or a colleague. Students not only benefit from getting perhaps a more comprehensive answer to their questions, but also knowledge that no one can know everything or even how much is still unknown. It is imperative in medicine that they learn and practice how to find appropriate information in order to make the most informed decision when it comes to patient care. These practices have also been shared by other medical educators (1). Clinical Reasoning Sessions also include students teaching the material to their colleagues, and we make it clear in our expectations that we much rather they describe their process and maybe come up with an incorrect conclusion than have short, although correct, answers which do not demonstrate process and reasoning. Another goal is to allow the students plenty of chances to practice answering questions of a clinical nature posed by faculty, and allow them to become comfortable asking faculty questions, well before they start their clerkships.
Manage expectations In my experience, students appreciate the ability to give feedback and share their expectations of their courses and programs. They also align these with their own expectations of themselves. Faculty and course directors work to resolve the students’ expectations with their own, and to assist students in forming and revising their expectations of and their role and responsibilities within the course. Educating during a pandemic has shined a light on and challenged the way we manage these expectations. A word I have heard my colleagues use lately is grace; we should extend grace to our students, to ourselves, and ask for grace from others. This is another way we can demonstrate how we deal with uncertainty, which can hopefully serve as a soft teaching point for our students.
Outside of the science classroom Developing skills to help us manage uncertainty extends to outside of our classroom. We hope that students will take the lessons and continue to use them in other classes, or outside of school altogether. Medical schools often offer electives, some of which are tied to wellness or extracurricular subjects. For example, some of our electives include Artful Thinking, in which students hone their skills of observation, application, and context, and Fundamentals of Improv, so that students can work on skills of listening, support, creativity, and quick thinking and response. Other schools and programs offer similar experiences for students (4,5). The narrative medicine program emphasizes skills of reflective writing to focus on the human side of medicine, reminding why we’re here in the first place (6).
Challenging ourselves and encouraging our creativity One of the most important lessons I learned in the transition to remote and hybrid education over the past six months was to face the uncertainty with planning, reflection, and flexibility. I am the type to have a backup plan to my backup plan, which I realized gave me the flexibility to be more creative in my course design and preparation. I feel that my courses benefitted from my ability to challenge myself, because of uncertainty, and I intend to continue to reflect and employ what I consider my ‘best practices’ even when we move back into the in-person classroom in the future. We are exposed to uncertainty every day. How we choose to frame our mindset, to help our students and ourselves tolerate or even embrace uncertainty can bring benefits both in and outside of the classroom.
References and further reading Twelve tips for thriving in the face of clinical uncertainty, accessed 8/28/20 https://www.tandfonline.com/doi/pdf/10.1080/0142159X.2019.1579308 What is Constructivism?, accessed 8/28/20 https://www.wgu.edu/blog/what-constructivism2005.html Inviting Uncertainty into the Classroom, accessed 8/28/20 http://www.ascd.org/publications/educational-leadership/oct17/vol75/num02/Inviting-Uncertainty-into-the-Classroom.aspx Teaching Medical Students the Art of Uncertainty, accessed 8/28/20 https://www.cuimc.columbia.edu/news/teaching-medical-students-art-uncertainty The Alda Method, Alda Center for Communicating Science, accessed 9/4/20 https://www.aldacenter.org/alda-method Narrative Medicine Program, Accessed 9/4/20 https://medicine.temple.edu/education/narrative-medicine-program The Diagnosis, Prognosis, and Treatment of Medical Uncertainty https://www.jgme.org/doi/pdf/10.4300/JGME-D-14-00638.1 The Ethics of Ambiguity: Rethinking the Role and Importance of Uncertainty in Medical Education and Practice https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC5497921&blobtype=pdf Helping Students Deal with Uncertainty in the classroom https://www.edutopia.org/blog/dealing-with-uncertainty-classroom-students-ben-johnson Learning: Theory and Research http://gsi.berkeley.edu/media/Learning.pdf
Rebecca Petre Sullivan, Ph.D.
Associate Professor of Physiology
Lewis Katz School of Medicine at Temple University
|Dr. Rebecca Petre Sullivan earned her Ph.D. in Physiology from the Lewis Katz School of Medicine at Temple University and completed a Post-Doctoral Fellowship in the Interdisciplinary Training Program in Muscle Biology at the University of Maryland School of Medicine. She taught undergraduate biology courses at Ursinus College and Neumann University. As an Associate Professor of Physiology and a Core Basic Science Educator, she is currently course director in the Pre-Clerkship curriculum at LKSOM and at the Kornberg School of Dentistry; in addition to teaching medical and dental students, she also teaches physiology in Temple’s podiatry school and in the physician assistant program. She is a member of Temple University’s Provost’s Teaching Academy. She was the recipient of the Mary DeLeo Prize for Excellence in Basic Science Teaching in 2020 and a Golden Apple Award in 2017 from LKSOM, and the Excellence in Undergraduate Teaching Award from Neumann University in 2012.|