August 4th, 2022
Uncertainty in Medicine — The “July Effect” and Beyond
Khalid A. Shalaby, MBBCh
When I first started residency, I was uncertain and hesitant with most of my clinical decisions. As medical students, we gain considerable knowledge through our medical school curriculum. But gaining knowledge and applying it to practice are two different sets of skills. Because I followed medical school graduation by a hiatus doing bench research, I needed support in both for both kinds of skills when I started residency. I had to brush up on my medical knowledge, and I had to apply it to practice as well as I could. My confidence in my abilities was rather low at that point. But with a lot of support and constructive feedback in the first few months of residency from mentors and colleagues, I was able to improve significantly.
The “July effect”
The public and some physicians fear the “July effect” — when freshly graduated physicians start practicing. Many presume that there is a drop in the quality of care in teaching hospitals during this month. However, the direct supervision of seniors and attendings in academic institutions, the eagerness of every recently graduated physician to do right by patients, and clinical studies all refute that notion.1 As residents become familiar with the practical aspects of the healthcare system and gain clinical exposure, they grow more confident. Personally, I am a bit more fearful of the “January effect” — when the stringent supervision of senior residents wanes, sleep deprivation piles up, and the long nights of winter break morale.
Uncertainty is everywhere
It is inescapable to have some degree of uncertainty when practicing medicine. It is a deeply uncomfortable, anxiety-generating feeling that afflicts many clinicians to varying degrees. This encompasses uncertainty regarding correct diagnoses, prognoses, best therapeutic approachs, mildly abnormal lab values, and imaging studies of undetermined significance. Perhaps the most glaring example is the COVID-19 pandemic. We can all recall how we didn’t fully understand its pathophysiology, and we didn’t how to prevent or treat it when the first wave of cases hit. We are yet to understand its full long-term effects on our patients. But beyond COVID-19, more subtle examples of uncertainty exist in our everyday practice.
I noticed during my chief year that residents (on average) tend to be less hesitant in their answers and more swift in their judgment midway through residency than by the end of training. It’s that sense of confidence that one gets with some (but not a lot of) experience. It’s knowing the presentation and treatment of the most common diseases and seeing enough of them to go into auto-pilot mode but not having enough experience to know ambiguous presentations and handle complications. The realization and feeling of humility that one cannot reasonably encompass all that knowledge and practice expertise typically sinks in during the last few months of residency.
It’s only natural to try to rid ourselves of these uncertainties. Therein, we can fall prey to pitfalls. We can turn to defense mechanisms might harm our patients, affect our own wellbeing, and impact the healthcare system at large. Suppressing uncertainty can lead to anchoring bias and misdiagnosis. It can lead to dismissing patients’ symptoms when they doesn’t fit a certain disease category, falsely attributing symptoms to psychosomatic disorders, or shrugging off patients’ fears about abnormal investigations. Or it can also lead to the exact opposite — doing extensive workups that could be more injurious to patients and burdensome to the healthcare system because of litigation fears.
In a recent study, primary care physicians, physicians with fewer years of experience, and physicians who lack a trusted advisor had a lower tolerance for uncertainty. In turn, physicians with lower tolerance of uncertainty had a higher likelihood of burnout, were less likely to be satisfied with their career, and were less engaged at work (NEJM JW Gen Med Jul 1 2022).2
How can we handle uncertainty in medicine?
We must continue to learn from every patient encounter. Every patient can educate us about their disease process and the adverse effects of a medication or procedure. No matter how many times we’ve diagnosed and treated patients with that disease, there’s always something new. I urge myself and others to tackle topics we’re least comfortable with headfirst, especially during training. Whether you find hyponatremia confusing, headaches difficult to diagnose accurately, or low back pain challenging, expand your knowledge about these topics and watch them gradually turn into your favorite topics.
But expanding your knowledge will only carry you so far. Uncertainty might be a greater challenge for generalists, such as hospitalists, primary care, family, and emergency medicine physicians who see a variety of pathology, but it still looms over even the best subspecialists who focus on a single disease category. Practicing tolerating uncertainty can aid us in making more thoughtful clinical decisions. Having a mentor/advisor during and after graduation from training programs to call on in a time of need is one of the greatest resources. We should discuss and be open with our colleagues and trainees about uncertainty. It may be helpful to receive official training in tolerating uncertainty. Perhaps most importantly, we need to partner with our patients by being honest and forthcoming about the limitations of science and medicine. Shared decision making is of paramount importance, especially when uncertainty is high. As the frontiers of science and medicine continue expanding, we’ll simultaneously have more answers and create more questions. Uncertainty in medicine is probably here to stay and the better we handle it as physicians, the more our patients benefit and the more at peace we’ll be.
- Metersky ML et al. Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: Is there a July effect? J Patient Saf 2022; 18:253. (https://doi.org/10.1097/PTS.0000000000000887)
- Begin AS et al. Factors associated with physician tolerance of uncertainty: An observational study. J Gen Intern Med 2022; 37:1415. (https://doi.org/10.1007/s11606-021-06776-8)