Health
Education
in
Practice:
Journal
of
Research
for
Professional
Learning
Vol. 4 | No. 1 |
2021
Research
&
Evaluation
article
(double
blind
peerreview)
Copyright is held
by
the
authors
with
the
first
publication
rights granted to
the
journal.
Conditions
of
sharing
are
defined
by
the
Creative Commons
License
AttributionShareAlikeNonCommercial 4.0
International
Citation: Magin,
P,
Tapley,
A,
Cooke,
G,
Holliday,
E,
Morgan, S, Ball,
J, Spike, N & van
Driel,
M
2021,
‘General practice
registrars’
clinical
uncertainty, and
in-consultation
information- and
assistanceseeking’, Health
Education
in
Practice: Journal
of Research for
Professional
Learning, vol. 4,
no.
1
https://doi.org/1
0.33966/hepj.4.1.
14765
General practice registrars’
clinical uncertainty, and
in-consultation informationand assistance-seeking
1 , Amanda Tapley
2 , Georga
Parker Magin
4 , Elizabeth Holliday
Cooke 1 , Susan Wearne
1 , Simon Morgan 5 , Jean Ball
6 , Neil Spike
7 , Mieke van Driel
3
Abstract
Purpose: To explore the association of Australian general
practitioner (GP) registrars’ responses to uncertainty with
their in-consultation information-, advice- and assistanceseeking.
Design/methodology/approach: A cross-sectional analysis of
data from the Registrar Clinical Encounters in Training
(ReCEnT) cohort study in four Australian states. In ReCEnT,
GP
registrars
record
details
of
60
consecutive
consultations, six-monthly, three times during training.
Outcome factors in logistic regression models included
whether the registrar sought in-consultation information
or assistance from (i) their supervisor or (ii) an
electronic or paper-based source. Independent variables
were the four independent subscales of the Physicians’
Reaction to Uncertainty (PRU) instrument, as well as
registrar, practice and consultation variables.
Findings: 589 registrars contributed details of 70,412
consultations.
On multivariable analysis, scores on the two ‘affective’
PRU subscales ‘anxiety regarding diagnosis/management’ (OR
1.03;
95% confidence
intervals
[CIs]
[1.01,
1.05],
p = 0.003) and ‘concern about a bad outcome’ (OR 1.03;
95% CIs [1.01, 1.06], p = 0.008) were significantly
associated with seeking supervisor assistance. There was
no association with ‘behavioural’ subscales ‘reluctance to
disclose uncertainty to patients’ and ‘reluctance to
disclose mistakes to physicians’.
None of the PRU subscales were significantly associated
with information-seeking from electronic or hard copy
sources.
Research implications: Further research is required to
explore the role of uncertainty within registrar–supervisor
5
Magin et al.
interactions and to define the role of supervisors in
registrars’ functional adaptation to clinical uncertainty
(including how best to support and train supervisors in
this role).
Practical
implications:
GP
registrars’
‘affective’
responses to clinical uncertainty are associated with
assistance-seeking from clinical supervisors. While inconsultation assistance-seeking may promote registrars’
tolerance of uncertainty, it may also contribute to
supervisor workload.
Originality/value: This is the first study to examine
trainees’ levels of uncertainty and their seeking of
information and assistance.
Limitations: We have not investigated whether registrars’
seeking assistance resolved or attenuated, for the index
problem, their anxiety or concern.
: Family Practice; General Practice; Education,
Medical, Graduate; Uncertainty; Preceptorship; Clinical
Decision-Making.
1
School of Medicine and Public Health, University of
Newcastle, Callaghan, Australia
2
Primary Care Clinical Unit, University of Queensland,
Brisbane, Australia
3
Research and Evaluation Unit, GP Synergy Regional
Training Organisation, Newcastle, Australia
4
Academic Unit of General Practice, Australian National
University, Canberra, Australia
5
GP Synergy Regional Training Organisation, Newcastle,
Australia
6
Statistical Support Unit (CReDITSS), Hunter Medical
Research Institute, Newcastle, Australia
7
Eastern Victoria General Practice Training, Melbourne,
Australia
Corresponding author: Professor Parker Magin , Discipline
of General Practice, University of Newcastle, University
Drive, Callaghan NSW 2308, parker.magin@newcastle.edu.au
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
6
Magin et al.
BACKGROUND
Uncertainty is unavoidable in clinical practice (Domen
2016; Gerrity et al. 1992; Han, Klein & Arora 2011),
particularly general practice (Gerrity et al. 1992;
O’Riordan et al. 2011). Undifferentiated illness and
presentation earlier in the course of illness are more
common in generalist practice than in specialist settings,
increasing levels of uncertainty (Alam et al. 2017).
Uncertainty also arises from general practitioners ([GPs],
family physicians) applying single disease guidelines in
the setting of generalist care of multimorbidity (Wallace
et al. 2015). Clinical uncertainty can have deleterious
effects across multiple domains (Strout et al. 2018),
including effects on both the clinician (influencing
professional satisfaction and burnout [Bovier and Perneger
2007; Cooke et al. 2013]), and on the health system in
which they practise (e.g., greater health costs [Allison
et al. 1998] including increased test-ordering [Pedersen
et al. 2015; van der Weijden et al. 2002]).
Management of the uncertainty intrinsic to general
practice is a core clinical skill of GPs (Malterud et al.
2017), but both established GPs (Stone 2014) and GP
registrars (vocational trainees/residents in general
practice) struggle with the effects of uncertainty (Cooke
et al. 2013; Danczak & Lea 2014). Registrars’ tolerance of
uncertainty may influence decisions to seek information and
assistance, including during consultations (Sturman, Jorm
& Parker 2020). Answering clinical questions generated
during clinical consultations is a vital aspect of patient
care (Del Fiol, Workman & Gorman 2014; Ely, Burch & Vinson
1992). Failure to find answers to the questions may lead
to suboptimal patient care decisions (Del Fiol, Workman &
Gorman 2014). Some questions can be pursued postconsultation but some must be answered in-consultation
(Gonzalez-Gonzalez et al. 2007). Given the breadth of their
practice, generalist clinicians have a particular need for
answering in-consultation clinical questions, and GPs when
using online resources are more likely to seek answers to
patient-related questions than are specialist physicians
(Bennett et al. 2005).
As well as informing immediate patient care, answering
in-consultation clinical questions is a rich source of
clinician learning (Brown et al. 2018; Phillips & Glasziou
2008). Registrars are early-career generalist clinicians
and have limited expertise and experience, needing ‘realtime’ answers to address knowledge gaps in immediate
patient care (Brown et al. 2018; Phillips & Glasziou 2008).
They also have an overarching educational need to improve
their clinical knowledge levels and move towards competence
in independent practice (Brown et al. 2018).
In many countries, GP registrars or trainees learn within
an apprenticeship-like model whereby they undergo a
structured program of centralised education (in Australia,
a minimum total of 125 hours in the first year of training).
However, most learning takes place in individual (mainly
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
7
Magin et al.
small, geographically dispersed) general practices under
the supervision of designated experienced GP supervisors
(Thomson et al. 2011; Wearne et al. 2012). Australian GP
registrars practise with considerable clinical autonomy,
but have recourse to advice or assistance from their
supervisor if requested. The responsibility for initiation
of this assistance lies with the registrar (Brown et al.
2018).
Registrars seek answers in-consultation to clinical
questions (in 21% of consultations) more often than do
established GPs (Magin et al. 2015). The most common sources
of information or advice are the supervisor (9.2% of
consultations [Morgan et al. 2015]; 6.9% of individual
problems managed [Magin et al. 2015; Morgan et al. 2015])
and electronic sources (6.5% of problems managed [Magin et
al. 2015]). Supervisors are preferentially consulted for
more complex problems (Magin et al. 2015). Appropriateness
of advice- and assistance-seeking has implications for
registrar learning, patient safety, and efficient use of
resources (supervisor time) (Ingham et al. 2020; Morrison
et al. 2015; Partanen 2018).
It is axiomatic that seeking in-consultation answers to
clinical questions entails some element of uncertainty on
the GP registrar’s part (Clement et al. 2015). It is also
plausible that the registrar’s individual response to
clinical
uncertainty
influences
decisions
to
seek
information and assistance. In this study, we sought to
establish the association of registrars’ responses to
uncertainty with their in-consultation information-,
advice- and assistance-seeking.
METHODS
This paper provides a cross-sectional analysis of data from
the Registrar Clinical Encounters in Training (ReCEnT)
study.
ReCEnT is an ongoing, multicentre cohort study of GP
registrars’ in-practice clinical experiences. Data included
in the current analysis were collected in four of
Australia’s then 17 Regional Training Providers (RTPs)
spanning four states. A total of five six-monthly rounds
of data collection were conducted from 2011 to 2013. RTPs
during this period were government-funded, not-for-profit,
geographically
defined
educational
and
training
organisations. Participants were GP registrars in general
practice-based training terms.
The detailed ReCEnT methodology has been described
previously (Morgan et al. 2012). Briefly, registrars
complete paper-based forms recording details of 60
consecutive consultations around the midpoint of each of
their three general practice training terms (six-monthly
for full-time registrars) as part of their training. This
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
8
Magin et al.
exercise is part of their routine educational program, with
registrars receiving detailed feedback on their recorded
clinical and educational activity. As well as this
educational use, registrars may also provide signed consent
for research use of their data. Some registrars at one of
the four RTPs also collected data during an optional fourth
training term. Patient demographics, clinical details and
educational
actions
(including
in-consultation
information- and assistance-seeking) are recorded for each
of the 60 patient encounters per term.
Registrar and practice demographics are documented in
each six-monthly collection period through a separate
questionnaire. During five data collection rounds (2011–
2013), clinical uncertainty scales were included in this
questionnaire.
The outcome variables in analyses were whether during a
consultation:
i.
the registrar sought advice or assistance from
their supervisor or the supervisor’s delegate GP if
the supervisor was unavailable (hereafter,
‘supervisor’)
ii.
the registrar sought information from an electronic
or paper-based source.
The variables of interest in this analysis were scores on
the Physicians’ Reaction to Uncertainty (PRU) subscales
(Gerrity et al. 1995). These subscales, each ranked on a
6-point Likert scale, measure a doctor’s ‘affective’
response to uncertainty (the first two subscales) and a
‘behavioural’ response of coping in response to uncertainty
(the third and fourth subscales). The PRU subscales are:
i.
ii.
iii.
iv.
anxiety due to uncertainty about
diagnosis/treatment: ‘anxiety’ (5 items)
concern about a bad outcome for the patient:
‘concern’ (3 items)
reluctance to disclose diagnosis/treatment
uncertainty to patients: ‘reluctance to disclose to
patients’ (5 items)
reluctance to disclose mistakes to physicians:
‘reluctance to disclose to physicians’ (2 items).
Responses to each item are scored from ‘strongly disagree’
(scored 1) to ‘strongly agree’ (scored 6), with relevant
items reverse scored and items summed to create total
subscale scores. The subscales are independent constructs,
and no overall ‘uncertainty’ score is calculated. The PRU
subscales have shown good reliability and validity (Gerrity
et al. 1990; Gerrity et al. 1995; Schneider et al. 2007).
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
9
Magin et al.
Other independent variables included registrar, patient,
practice and consultation variables. These variables are
included in Supplementary Table S1. Practice postcode was
used to define the Australian Standard Geographical
Classification-Remoteness Area classification (the degree
of rurality) of the practice location, and to define the
practice location’s Socio-Economic Index for Areas’ ‘Index
of Relative Socio-Economic Disadvantage’ decile.
The unit of analysis was the individual consultation.
Proportions of consultations for which (i) supervisor
advice or assistance were sought and (ii) information was
sought from electronic or hard copy sources were calculated
with 95% confidence intervals (CIs), adjusted for
clustering within registrars.
To test associations of a registrar seeking (i)
supervisor advice or assistance and (ii) information from
electronic or hard copy sources, simple and multiple
logistic regression were used within a generalised
estimating equations framework to account for clustering
of patients within registrars. An exchangeable working
correlation structure was assumed. Covariates with a pvalue of < 0.2 on univariate analysis were included in the
multivariable analyses. Covariates that had a small effect
size and a p-value > 0.2 in the multivariable model were
tested for removal from the model. If the covariate’s
removal did not substantively change the resulting model,
the covariate was not included in the final multivariable
model.
We conducted separate analyses for each of the four
separate PRU subscales for each of the two outcomes. For
the fourth PRU subscale, ‘reluctance to disclose mistakes
to physicians’, a printing error resulted in only two rounds
of complete data being collected. Only these complete data
were used in analyses involving this subscale.
Mean substitution was used to reduce the number of
missing values for the three uncertainty scores ‘anxiety’,
‘concern’ and ‘reluctance to disclose to patients’,
dependent on no more than half of the items being missing.
Revised total scores were created for all outcomes using
the recoded items. For ‘reluctance to disclose to
physicians’, mean substitution was not employed, as there
are only two items in this scale.
To assess the magnitude of associations with informationor assistance-seeking that were statistically significant,
we calculated Cohen’s d as a standardised measure of effect
(using univariate findings).
Analyses were programmed using STATA 13.1 and SAS V9.4.
P-values < 0.05 were considered statistically significant.
Ethical approval was obtained from the University of
Newcastle Human Research Ethics Committee (Ref. No. H-2009–
0323).
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
10
Magin et al.
RESULTS
A total of 589 individual registrars (response rate 93.6%)
contributed details of 70,412 individual consultations. The
characteristics of the participating registrars and
practices are presented in Table 1.
Table 1: Characteristics of participating registrars
and participating general practices.
Variable
Registrar variables (n=589)
Class
n (%) *
Registrar Gender
Female
387
(66%)
439
(76%)
Qualified as a doctor in Australia
Registrar or practice variables by term (n=1184)
Registrar Training Term
Term 1
435
(37%)
Term 2
440
(37%)
Term 3
255
(22%)
Term 4
54 (4.6%)
Registrar age (years)
Mean (SD)
33.1 (6.8)
Registrar worked at the practice
360
previously
(31%)
Registrar works fulltime
911
(79%)
Does the practice routinely Bulk Bills all
208
patients
(18%)
Number of GPs† working at the
1-4
373
(32%)
training practice
5-10+
786
(68%)
Rurality classification of practice
Major City
717
(61%)
Inner Regional
317
(27%)
Outer regional, remote or very 150
remote
(13%)
SEIFA‡ Index (decile) of practice
Mean (SD)
5.5 (2.9)
*Numbers may not add up to 1184 for registrar/practice variables by term due to missing data.
†General Practitioners (GPs)
‡SEIFA – Socio-economic Index for Area (Index of Disadvantage).
Advice or assistance was sought from the registrars’
supervisor in 8.8% (95% CI: 8.1–9.5) of consultations
(n = 6,184). Information was sought from electronic (8.4%)
or hard copy (1.7%) sources in 9.8% (95% CI: 8.8–10.7) of
consultations (n = 6,869). More than one source of
information or assistance could be sought in the one
consultation.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
11
Magin et al.
The characteristics associated with seeking advice or
assistance from a supervisor and seeking information from
an electronic or hard copy source are presented in
Supplementary Tables S1 and S2, respectively. ‘Anxiety’
(p < 0.001), ‘concern’ (p < 0.001) and ‘reluctance to
disclose to patients’ (p = 0.019), but not ‘reluctance to
disclose to physicians’ (p = 0.98), were significantly
associated with seeking help from a supervisor on
univariate analysis. ‘Anxiety’ (p = 0.002), but neither
‘concern’ (p = 0.12) nor ‘reluctance to disclose to
patients’ (p = 0.84), nor ‘reluctance to disclose to
physicians’ (p = 0.92), was significantly associated with
seeking information from an electronic or hard copy source
on univariate analysis.
Seeking supervisor advice or assistance
The regression models including ‘anxiety’, ‘concern’,
‘reluctance to disclose to patients’ and ‘reluctance to
disclose to physicians’, respectively, are presented in
Tables 2, 3, 4 and 5. On multivariable analysis, ‘anxiety’
(OR 1.03; 95% CIs [1.01, 1.05], p = 0.003) and ‘concern’
(OR
1.03;
95% CIs
[1.01,
1.06],
were
p = 0.008)
significantly associated with seeking supervisor advice or
assistance. ‘Reluctance to disclose to patients’ (OR 1.00;
95% CIs [0.98, 1.02], p = 0.90) and ‘reluctance to disclose
to physicians’ (OR 1.01; 95% CIs [0.96, 1.06], p = 0.73)
were not significantly associated with seeking supervisor
advice or assistance.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
12
Table 2: Univariate and adjusted associations with seeking advice or assistance from a supervisor and
with seeking information from an electronic or hard-copy source, including associations with the scores
on
the
Physicians’
Reaction
to
Uncertainty
subscale
‘Anxiety
due
to
uncertainty
about
diagnosis/treatment’.
Variable
Uncertainty Variables
Anxiety due to uncertainty
Class
Patient Variables
Patient age group
0-14
Referent 15-34
35-64
65+
Patient gender
Female
Patient/practice status
New to practice
Referent: Existing patient
New to registrar
Registrar Variables
Registrar gender
Female
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95%
OR (95%
CI)
P
CI)
P
Seeking assistance from a book or electronic
resource
Univariate
Adjusted
OR (95% CI)
P
OR (95% CI)
P
1.07 (1.05, <0.001
1.10)
1.03 (1.01, 0.003
1.05)
1.03 (1.01, 1.05) 0.002
1.00 (0.99, 1.02)
0.61
1.06
1.15)
1.06
1.14)
1.12
1.22)
0.89
0.94)
0.96
1.06)
0.85
0.91)
1.26
1.38)
1.06
1.14)
1.22
1.34)
0.86
0.91)
0.77
0.87)
0.88
0.95)
(1.15, <0.001
1.05 (0.98, 1.14) 0.18
1.19 (1.09, 1.31)
0.001
(0.98, 0.14
0.87 (0.82, 0.93) <0.001
0.85 (0.79, 0.92)
<0.001
(1.11, <0.001
0.70 (0.64, 0.77) <0.001
0.69 (0.62, 0.76)
<0.001
(0.82, <0.001
1.04 (0.98, 1.09) 0.20
1.05 (0.98, 1.11)
0.15
(0.68, <0.001
1.10 (0.99, 1.22) 0.066
1.00 (0.89, 1.11)
0.96
(0.82, 0.001
1.09 (1.03, 1.15) 0.002
1.05 (0.98, 1.11)
0.14
1.21 (0.95, 1.54) 0.12
1.17 (0.94, 1.45)
0.16
(0.98, 0.16
(1.00, 0.067
(1.03, 0.006
(0.85, <0.001
(0.86, 0.41
(0.79, <0.001
13
13
Magin et al.
Variable
Training term/post
Class
Term 2
Referent: Term 1
Term 3
Term 4
Worked at practice previously
Yes
Registrar age
Mean(SD)
Practice Variables
RTP*
RTP 2
Referent: RTP 1
RTP 3
RTP 4
Practice routinely bulk bills
Yes
Consultation Variables
Follow-up ordered
Yes
Learning goals generated
Yes
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95%
OR (95%
CI)
P
CI)
P
0.53 (0.47, <0.001
0.66 (0.58, <0.001
0.60)
0.76)
0.33 (0.26, <0.001
0.49 (0.38, <0.001
0.42)
0.62)
0.18 (0.13, <0.001
0.31 (0.21, <0.001
0.26)
0.44)
0.60 (0.53, <0.001
0.91 (0.79, 0.21
0.68)
1.05)
0.96 (0.94, 0.001
0.97 (0.95, <0.001
0.98)
0.99)
1.04
1.40)
1.40
1.93)
1.30
1.63)
0.80
1.02)
(0.77, 0.79
(1.02, 0.040
(1.03, 0.028
(0.63, 0.068
1.66 (1.53, <0.001
1.79)
6.43 (5.79, <0.001
7.15)
1.28
1.78)
1.09
1.53)
1.62
2.02)
0.74
0.92)
Seeking assistance from a book or electronic
resource
Univariate
Adjusted
OR (95% CI) P
0.70 (0.61, 0.81) <0.001
OR (95% CI)
0.83 (0.72, 0.95)
P
0.008
0.68 (0.58, 0.80) <0.001
0.86 (0.72, 1.03)
0.11
0.62 (0.37, 1.03) 0.067
0.68 (0.46, 1.00)
0.050
(0.92, 0.15
0.66 (0.48, 0.92) 0.014
0.62 (0.43, 0.88)
0.008
(0.78, 0.61
1.28 (0.92, 1.79) 0.15
0.95 (0.69, 1.31)
0.76
(1.29, <0.001
0.83 (0.66, 1.04) 0.11
0.81 (0.64, 1.02)
0.075
(0.60, 0.007
-
-
-
1.39 (1.31, 1.47) <0.001
1.19 (1.11, 1.27)
<0.001
3.82 (3.38, 4.33) <0.001
3.50 (3.12, 3.92)
<0.001
1.17 (1.07, <0.001
1.27)
4.55 (4.07, <0.001
5.08)
-
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
14
Magin et al.
Variable
Pathology ordered
Medication prescribed
Class
Consult duration
Mean(SD)
Chronic disease
Yes
Imaging ordered
Yes
Referral made
Yes
Number of problems
Mean(SD)
Yes
*RTP – Regional Training Provider
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95%
OR (95%
CI)
P
CI)
P
0.90
0.95)
1.06
1.06)
1.09
1.17)
1.80
1.96)
2.03
2.18)
1.06
1.10)
(0.86, 0.001
(1.05, <0.001
(1.03, 0.007
(1.66, <0.001
(1.90, <0.001
(1.02, 0.003
1.06
1.13)
1.05
1.06)
0.81
0.88)
1.24
1.37)
1.37
1.49)
0.82
0.86)
Seeking assistance from a book or electronic
resource
Univariate
Adjusted
(1.00, 0.040
OR (95% CI) P
1.19 (1.11, 1.27) <0.001
1.79 (1.66, 1.92) <0.001
OR (95% CI)
1.05 (0.97, 1.13)
1.97 (1.81, 2.13)
P
0.25
<0.001
(1.05, <0.001
1.02 (1.02, 1.02) <0.001
1.01 (1.01, 1.02)
<0.001
1.09 (1.05, 1.12) <0.001
0.96 (0.93, 1.00)
0.078
(0.75, <0.001
(1.12, <0.001
(1.26, <0.001
(0.77, <0.001
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
15
Magin et al.
Table 3: Univariate and adjusted associations with seeking advice or assistance from a supervisor and
with seeking information from an electronic or hard-copy source, including associations with the scores
on the Physicians’ Reaction to Uncertainty subscale ‘Concern about a bad outcome for the patient’.
Variable
Class
Uncertainty Variables
Concern about a bad Mean(SD)
outcome
Patient Variables
Patient age group
0-14
Referent 15-34
35-64
65+
Patient gender
Female
Patient/practice status
New to practice
Referent: Existing patient New to registrar
Registrar Variables
Registrar gender
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95% CI) P
OR (95% CI)
P
Seeking assistance from a book or
electronic resource
Univariate
Adjusted
OR (95% CI) P
OR (95% CI) P
1.07
1.10)
(1.04, <0.001
1.03
1.06)
(1.01, 0.008
1.02
1.06)
(0.99,0.12
1.00
1.03)
(0.98,0.76
1.06
1.15)
1.06
1.14)
1.12
1.22)
0.89
0.94)
0.96
1.06)
0.85
0.91)
(0.98, 0.16
1.26
1.38)
1.06
1.14)
1.22
1.34)
0.86
0.91)
0.77
0.87)
0.88
0.95)
(1.15, <0.001
1.05
1.14)
0.87
0.93)
0.70
0.77)
1.04
1.09)
1.10
1.22)
1.09
1.15)
(0.98,0.18
1.19
1.30)
0.85
0.92)
0.69
0.76)
1.05
1.11)
1.00
1.12)
1.05
1.11)
(1.09,0.001
1.21
1.54)
(0.95,0.12
1.18
1.46)
(0.95,0.15
(1.00, 0.067
(1.03, 0.006
(0.85, <0.001
(0.86, 0.41
(0.79, <0.001
(0.98, 0.14
(1.11, <0.001
(0.82, <0.001
(0.68, <0.001
(0.82, 0.001
Female
(0.82,<0.001
(0.64,<0.001
(0.98,0.20
(0.99,0.066
(1.03,0.002
(0.79,<0.001
(0.62,<0.001
(0.98,0.14
(0.89,0.97
(0.98,0.14
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
16
Magin et al.
Variable
Training term/post
Class
Term 2
Referent: Term 1
Term 3
Term 4
Worked at
previously
Registrar age
practice Yes
Mean(SD)
Practice Variables
RTP*
RTP 2
Referent: RTP 1
RTP 3
RTP 4
Practice routinely bulk Yes
bills
Consultation Variables
Follow-up ordered
Yes
Learning
generated
goals Yes
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95% CI) P
OR (95% CI)
0.53
(0.47, <0.001
0.67
(0.59,
0.60)
0.77)
0.33
(0.26, <0.001
0.48
(0.38,
0.42)
0.60)
0.18
(0.13, <0.001
0.31
(0.21,
0.26)
0.45)
0.60
(0.53, <0.001
0.89
(0.77,
0.68)
1.02)
0.96
(0.94, 0.001
0.97
(0.95,
0.98)
0.99)
1.04
1.40)
1.40
1.93)
1.30
1.63)
0.80
1.02)
(0.77, 0.79
1.66
1.79)
6.43
7.15)
(1.53, <0.001
(1.02, 0.040
(1.03, 0.028
(0.63, 0.068
(5.79, <0.001
P
<0.001
<0.001
<0.001
Seeking assistance from a book or
electronic resource
Univariate
Adjusted
OR (95% CI) P
OR (95% CI) P
0.70 (0.61,<0.001
0.83 (0.73,0.007
0.81)
0.95)
0.68 (0.58,<0.001
0.86 (0.72,0.078
0.80)
1.02)
0.62 (0.37,0.067
0.68 (0.46,0.047
1.03)
0.99)
0.098
0.001
1.33
1.85)
1.08
1.52)
1.63
2.05)
0.74
0.91)
(0.96, 0.087
1.17
1.27)
4.53
5.07)
(1.07, <0.001
(0.77, 0.66
(1.30, <0.001
0.66
0.92)
1.28
1.79)
0.83
1.04)
(0.48,0.014
1.39
1.47)
3.82
4.33)
(1.31,<0.001
(0.92,0.15
(0.66,0.11
0.62
0.89)
0.94
1.31)
0.81
1.02)
(0.44,0.009
1.19
1.27)
3.50
3.92)
(1.11,<0.001
(0.68,0.72
(0.64,0.077
(0.60, 0.005
(4.06, <0.0001
(3.38,<0.001
(3.13,<0.001
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
17
Magin et al.
Variable
Pathology ordered
Class
Medication prescribed
Yes
Consult duration
Mean(SD)
Chronic disease
Yes
Imaging ordered
Yes
Referral made
Yes
Number of problems
Mean(SD)
*RTP
– Regional Training Provide
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95% CI) P
OR (95% CI)
0.90
0.95)
1.06
1.06)
1.09
1.17)
1.80
1.96)
2.03
2.18)
1.06
1.10)
(0.86, <0.001
(1.05, <0.001
(1.03, 0.007
(1.66, <0.001
(1.90, <0.001
(1.02, 0.003
1.07
1.13)
1.05
1.06)
0.81
0.88)
1.24
1.36)
1.36
1.49)
0.82
0.86)
P
(1.00, 0.037
(1.05, <0.001
Seeking assistance from a book or
electronic resource
Univariate
Adjusted
OR (95% CI) P
OR (95% CI) P
1.19 (1.11,<0.001
1.05 (0.97,0.25
1.27)
1.13)
1.79 (1.66,<0.001
1.97 (1.81,<0.001
1.92)
2.13)
1.02 (1.02,<0.001
1.01 (1.01,<0.001
1.02)
1.02)
(0.75, <0.001
(1.12, <0.001
(1.25, <0.001
(0.77, <0.001
1.09
1.12)
(1.05,<0.001
0.96
1.00)
(0.92,0.075
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
18
Table 4: Univariate and adjusted associations with seeking advice or assistance from a supervisor and
with seeking information from an electronic or hard-copy source, including associations with the scores
on the Physicians’ Reaction to Uncertainty subscale ‘Reluctance to disclose diagnosis/treatment
uncertainty to patients’
Variable
Class
Uncertainty Variables
Reluctance to disclose uncertainty to Mean(SD)
patients
Patient Variables
Patient age group
0-14
Referent 15-34
35-64
65+
Patient gender
Female
Patient/practice status
New
practice
New
registrar
Referent: Existing patient
Registrar Variables
Registrar gender
Female
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95% CI) P
OR (95% CI) P
1.03
1.06)
1.06
1.15)
1.06
1.14)
1.12
1.22)
0.89
0.94)
to 0.96
1.06)
to 0.85
0.91)
1.39
1.73)
(1.01, 0.019
1.00
1.02)
1.00 (0.97, 1.02)
0.84
0.99 (0.97, 1.01)
0.26
1.26
1.37)
(1.00, 0.067 1.06
1.14)
(1.03, 0.006 1.22
1.33)
(0.85, <0.001 0.86
0.91)
(0.86, 0.41
0.77
0.87)
(0.79, <0.001 0.88
0.95)
(1.15, <0.001 1.05 (0.98, 1.14)
0.18
1.19 (1.09, 1.31)
<0.001
(0.98, 0.13
0.87 (0.82, 0.93)
<0.001
0.85 (0.79, 0.92)
<0.001
(1.11, <0.001 0.70 (0.64, 0.77)
<0.001
0.69 (0.62, 0.76)
<0.001
(0.81, <0.001 1.04 (0.98, 1.09)
0.20
1.05 (0.98, 1.11)
0.15
(0.68, <0.001 1.10 (0.99, 1.22)
0.066
1.00 (0.89, 1.12)
0.98
(0.82, 0.001 1.09 (1.03, 1.15)
0.002
1.05 (0.98, 1.11)
0.14
(1.11, 0.004
(0.93, 0.21
0.12
1.20 (0.96, 1.49)
0.10
(0.98, 0.16
1.15
1.43)
(0.98, 0.90
Seeking assistance from a book or electronic
resource
Univariate
Adjusted
OR (95% CI)
P
OR (95% CI)
P
1.21 (0.95, 1.54)
19
19
Magin et al.
Variable
Training term/post
Class
Term 2
Referent: Term 1
Term 3
Term 4
Worked at practice previously
Yes
Registrar age
Mean(SD)
Practice Variables
RTP*
RTP 2
Referent: RTP 1
RTP 3
RTP 4
Practice routinely bulk bills
Yes
Consultation Variables
Follow-up ordered
Yes
Learning goals generated
Yes
Pathology ordered
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95% CI) P
OR (95% CI) P
0.53
(0.47, <0.001 0.67
(0.59, <0.001
0.60)
0.77)
0.33
(0.26, <0.001 0.47
(0.38, <0.001
0.42)
0.59)
0.18
(0.13, <0.001 0.30
(0.21, <0.001
0.26)
0.44)
0.60
(0.53, <0.001 0.89
(0.77, 0.11
0.68)
1.03)
0.96
(0.94, 0.001 0.97
(0.95, <0.001
0.98)
0.98)
Seeking assistance from
resource
Univariate
OR (95% CI)
P
0.70 (0.61, 0.81)
<0.001
a book or electronic
Adjusted
OR (95% CI)
0.83 (0.72, 0.95)
P
0.006
0.68 (0.58, 0.80)
<0.001
0.85 (0.71, 1.01)
0.065
0.62 (0.37, 1.03)
0.067
0.67 (0.45, 0.98)
0.039
1.04
1.40)
1.40
1.93)
1.30
1.63)
0.80
1.02)
(0.77, 0.79
1.39
1.96)
1.07
1.50)
1.63
2.03)
0.73
0.91)
(0.99, 0.057 0.66 (0.48, 0.92)
0.014
0.63 (0.44, 0.89)
0.010
(0.76, 0.70
1.28 (0.92, 1.79)
0.15
0.92 (0.67, 1.28)
0.63
(1.30, <0.001 0.83 (0.66, 1.04)
0.11
0.82 (0.65, 1.04)
0.096
1.66
1.79)
6.43
7.15)
(1.53, <0.001 1.16
1.26)
(5.79, <0.001 4.52
5.06)
(1.07, <0.001 1.39 (1.31, 1.47)
<0.001
1.19 (1.11, 1.27)
<0.001
(4.03, <0.001 3.82 (3.38, 4.33)
<0.001
3.51 (3.13, 3.92)
<0.001
1.19 (1.11, 1.27)
<0.001
1.05 (0.97, 1.13)
0.242
(1.02, 0.040
(1.03, 0.028
(0.63, 0.068
(0.59, 0.005
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
20
Magin et al.
Variable
Medication prescribed
Class
Yes
Consult duration
Mean(SD)
Chronic disease
Yes
Imaging ordered
Yes
Referral made
Yes
Number of problems
Mean(SD)
*RTP
– Regional Training Provider
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95% CI) P
OR (95% CI) P
0.90
(0.86, 0.001 1.06
(1.00, 0.038
0.95)
1.13)
1.06
(1.05, <0.001 1.05
(1.05, <0.001
1.06)
1.06)
1.09
(1.03, 0.007 0.81
(0.75, <0.001
1.17)
0.88)
1.80
(1.66, <0.001 1.23
(1.12, <0.001
1.96)
1.36)
2.03
(1.90, <0.001 1.36
(1.25, <0.001
2.18)
1.48)
1.06
(1.02, 0.003 0.81
(0.77, <0.001
1.10)
0.86)
Seeking assistance from
resource
Univariate
OR (95% CI)
P
1.79 (1.66, 1.92)
<0.001
a book or electronic
Adjusted
OR (95% CI)
1.97 (1.81, 2.13)
P
<0.001
1.02 (1.02, 1.02)
<0.001
1.01 (1.01, 1.02)
<0.001
1.09 (1.05, 1.12)
<0.001
0.96 (0.92, 1.00)
0.075
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
21
Magin et al.
Table 5: Univariate and adjusted associations with seeking advice or assistance from a supervisor and
with seeking information from an electronic or hard-copy source, including associations with the scores
on the Physicians’ Reaction to Uncertainty subscale ‘Reluctance to disclose mistakes to physicians’
Variable
Class
Uncertainty Variables
Reluctant
to
disclose Mean(SD)
uncertainty to other doctors
Patient Variables
Patient age group
Referent 15-34
Patient gender
Patient/practice status
Referent: Existing patient
Registrar Variables
Registrar gender
Registrar FTE* status
Training term/post
Referent: Term 1
0-14
35-64
65+
Female
New to practice
New to registrar
Female
Part-time
Term 2
Term 3
Term 4
Worked at practice previously Yes
Registrar age
Mean(SD)
Practice Variables
Rurality
Inner regional
Seeking assistance from a Supervisor
Univariate
Adjusted
OR (95% CI)
P
OR (95% CI)
1.00 (0.94, 1.07)
0.99
P
1.01 (0.96, 1.06) 0.73
Seeking assistance from a book or electronic
resource
Univariate
Adjusted
OR (95% CI)
P
OR (95% CI)
P
1.00 (0.96, 1.05) 0.92
1.03 (0.98, 1.09) 0.20
1.05 (0.94, 1.17) 0.42
1.20 (1.06, 1.35) 0.003
0.85 (0.78, 0.94) 0.001 0.84 (0.75, 0.93) 0.001
0.69 (0.60, 0.79) <0.001 0.68 (0.59, 0.78) <0.001
0.90 (0.84, 0.97)
0.97 (0.83, 1.14)
0.80 (0.74, 0.88)
0.004
0.75
<0.001
0.85 (0.78, 0.92) 0.001
0.78 (0.66, 0.92) 0.003
0.87 (0.78, 0.96) 0.007
1.29 (0.97, 1.71)
1.40 (0.99, 1.99)
0.51 (0.43, 0.59)
0.19 (0.15, 0.25)
0.11 (0.07, 0.17)
0.49 (0.39, 0.62)
0.98 (0.96, 1.00)
0.081
0.058
<0.001
<0.001
<0.001
<0.001
0.12
1.30 (0.98, 1.73)
1.23 (0.93, 1.63)
0.65 (0.53, 0.80)
0.31 (0.24, 0.42)
0.25 (0.14, 0.42)
0.77 (0.61, 0.99)
0.96 (0.95, 0.98)
1.04 (0.74, 1.47)
0.81
0.88 (0.66, 1.17) 0.38
0.068
0.15
<0.001
<0.001
<0.001
0.038
<0.001
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
22
Magin et al.
Variable
Referent: Major city
RTP†
Referent: RTP 1
Seeking assistance from
Univariate
Class
OR (95% CI)
P
Outer regional, remote, very 0.72 (0.53, 0.99) 0.041
remote
RTP 2
RTP 3
RTP 4
Consultation Variables
Follow-up ordered
Yes
Learning goals generated
Yes
Pathology ordered
Medication prescribed
Yes
Consult duration
Mean(SD)
Chronic disease
Yes
Imaging ordered
Yes
Referral made
Yes
Number of problems
Mean(SD)
*FTE – full-time equivalent
†RTP – Regional Training Provider
1.88 (1.72, 2.05)
7.19 (6.22, 8.31)
<0.001
<0.001
1.06 (1.05, 1.06)
1.09 (0.99, 1.20)
1.92 (1.71, 2.16)
2.11 (1.92, 2.32)
1.06 (1.01, 1.11)
<0.001
0.075
<0.001
<0.001
0.0287
Seeking assistance from a book or electronic
a Supervisor
resource
Adjusted
Univariate
Adjusted
OR (95% CI)
P
OR (95% CI)
P
OR (95% CI)
P
0.67 (0.47, 0.95) 0.026
0.52 (0.35, 0.75) 0.001
1.25 (0.84, 1.87) 0.27
0.72 (0.54, 0.96) 0.025
1.33 (1.21, 1.47) <0.001 1.33 (1.24, 1.43)
4.86 (4.21, 5.60) <0.001 4.20 (3.60, 4.90)
1.19 (1.08, 1.31)
1.85 (1.69, 2.04)
1.05 (1.04, 1.05) <0.001 1.02 (1.02, 1.02)
0.82 (0.73, 0.93) 0.001
1.27 (1.11, 1.45) 0.001
1.41 (1.25, 1.59) <0.001
0.80 (0.75, 0.86) <0.001
<0.001
<0.001
0.006
<0.001
<0.001
0.52 (0.34, 0.79) 0.002
1.27 (0.85, 1.89) 0.24
0.81 (0.60, 1.09) 0.16
1.17 (1.08, 1.28)
3.94 (3.32, 4.67)
1.10 (0.98, 1.24)
1.97 (1.77, 2.19)
1.01 (1.00, 1.01)
<0.001
<0.001
0.098
<0.001
<0.001
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No. 1, 2021
23
Magin et al.
Seeking information from an electronic or hard
copy source
The regression models including ‘anxiety’, ‘concern’,
‘reluctance to disclose to patients’ and ‘reluctance to
disclose to physicians’, respectively, are also presented
in Tables 2, 3, 4 and 5. On multivariable analyses, neither
‘anxiety’ (OR 1.00; 95% CIs [0.99, 1.02], p = 0.61), nor
‘concern’ (OR 1.00; 95% CIs [0.98, 1.03], p = 0.76), nor
‘reluctance to disclose to patients’ (OR 0.99; 95% CIs
[0.97, 1.01], p = 0.26), nor ‘reluctance to disclose to
physicians’ (OR 1.03; 95%CIs [0.98, 1.09], p = 0.20) were
significantly associated with seeking information from an
electronic or hard copy source.
For advice- or assistance-seeking from a supervisor,
Cohen’s d for ‘anxiety’ and ‘concern’ were 0.32 and 0.21,
respectively.
CONCLUSIONS
We found that ‘affective’ responses to uncertainty
(‘anxiety’ and ‘concern’), but not ‘behavioural’ responses
(reluctance to disclose uncertainty to patients or mistakes
to physicians), were associated with registrars seeking inconsultation advice or assistance from their supervisor.
The effect sizes for these associations were modest (small
or small-to-moderate Cohen’s d of 0.32 and 0.21). There
were
no
significant
associations
of
responses
to
uncertainty with seeking information from electronic or
hard copy sources.
We are not aware of any previous studies examining the
association of clinical uncertainty and information- or
assistance-seeking.
‘Affective’ responses to uncertainty
‘Direct supervision’ is central to the registrar–supervisor
educational model (Cottrell et al. 2002; Ingham et al.
2020; Partanen 2018). An initial implication of our
findings is that high levels of registrar ‘affective’
responses to uncertainty create work for supervisors. How
they interpret or manage this work is likely to be context
dependent. In Australia, supervisors are engaged in care
of their own patients concurrently with supervising
registrars and have finite remunerated teaching time
(Ingham et al. 2020).
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
24
Magin et al.
This
interpretation
may
suggest
high
levels
of
‘affective’ responses to uncertainty may be problematic for
supervisors (Sturman, Jorm & Parker 2020). However, the
association may also reflect a functional response of the
supervisor–registrar dyad to registrar uncertainty. Higher
‘affective’ responses with less tolerance of uncertainty
in doctors (including trainees) are associated with less
professional satisfaction (Bovier & Perneger 2007) and
higher risk of burnout (Cooke et al. 2013). Lower tolerance
of uncertainty has also been associated with generation of
greater health costs (Allison et al. 1998) including
increased test-ordering. As well as financial consequences,
increased test-ordering has patient safety implications
(Deyo 2002). A particular consideration concerning the
uncertainty–anxiety nexus in trainee clinicians is that
anxiety and stress can impair learning (Conrad et al. 2012;
Pekrun et al. 2002). Observation of interactions between
registrars and supervisors suggests registrars often seek
reassurance that their plans for patients are appropriate
rather than seek information per se (Brown et al. 2018).
Thus, if registrars seeking in-consultation supervisor
assistance were to allay anxiety and concern arising from
uncertainty, there would be benefits to registrars,
patients and health systems. This would be especially so
if these registrar–supervisor interactions educationally
addressed coping with uncertainty generically (O’Riordan
et al. 2011; Sturman, Jorm & Parker 2020), as well as the
specific uncertainty prompting the assistance-seeking.
Our previous analyses in this registrar population have
demonstrated that seeking advice or assistance from a
supervisor declines markedly as registrars progress through
training (Morgan et al. 2015). The decline in seeking
information from an electronic or hard copy source is not
as marked (Magin et al. 2015). The causes for the decline
in seeking supervisor assistance are likely to include
greater experience in the general practice clinical
environment (Sturman, Jorm & Parker 2020) and greater
knowledge levels (leading to less uncertainty). Given our
findings of an association with ‘affective’ responses to
uncertainty, any declines in levels of these responses to
uncertainty might also lead to less assistance-seeking.
However, a further likely cause of the decline in
registrars’ recourse to supervisor assistance may be
‘supply-driven’ rather than ‘demand-driven’. The time
supervisors within the Australian general practice training
program are remunerated for registrar teaching decreases
appreciably for each term of their registrar’s training
program. This creates benchmarks for approximately how much
time is appropriate for registrars to require (and for
supervisors to provide) at each stage of training. A
schedule of reducing supervisor–registrar interaction is
consistent with the need for registrars’ progression to
autonomy within the apprenticeship-like model (Wearne et
al. 2012) in preparation for unsupervised practice (Kennedy
et al. 2005). But any mismatch in individual registrars
between decreases in uncertainty and/or responses to
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
25
Magin et al.
uncertainty and reduced supervisor availability could be
problematic (if supervisory support does, indeed, attenuate
the negative effects of responses to uncertainty on
registrars and their practice behaviours).
The lack of association of responses to clinical
uncertainty with information-seeking from electronic or
hard copy sources contrasts with the associations of
‘affective’ responses we found with seeking supervisor
assistance. This may reflect electronic and hard copy (nonhuman) resources being better at addressing clinical
uncertainty itself, rather than the affective responses to
uncertainty. These ‘affective’ responses may be best
addressed within the supportive context of the registrar–
supervisor ‘community of practice’ (Clement et al. 2015;
Morrison et al. 2015)—although, for some registrars this
may be more comfortable out of the patient’s hearing
(Sturman et al. 2020).
‘Behavioural’ responses to uncertainty
Reluctance to disclose uncertainty to patients and
reluctance to disclose mistakes to physicians, as suggested
by some qualitative research (Sturman, Jorm & Parker 2020),
would be problematic in terms of patient safety (and
registrar learning) if they led to registrars failing to
seek appropriate advice or assistance from their supervisor
(Kennedy et al. 2009; Partanen 2018). However, we found no
evidence for such an association of ‘reluctance’ responses
and seeking supervisor advice or assistance.
Addressing the problem programmatically
How specialist GP vocational training programs should
address the issue of responses to clinical uncertainty is
an important question. Reducing uncertainty itself is
desirable.
Providing
access
to,
and
training
in,
utilisation of clinical information sources may reduce
clinical uncertainty (Axelson et al. 2007). We have found
‘affective’ responses to uncertainty to be associated with
inappropriate antibiotic prescribing by GP registrars
(manuscript in preparation). Reducing uncertainty (e.g.,
by
point-of-care
testing)
could
improve
antibiotic
prescribing rates (Stanton, Francis & Butler 2010).
However, a certain amount of uncertainty is inevitable in
medicine,
and
helping
registrars
learn
to
manage
uncertainty
and
their
own
affective
responses
to
uncertainty is key.
It has been noted that attenuation of responses to
uncertainty with time in practice, rather than formal
educational intervention, may be the essential element
(White & Williams 2017). Later training terms in our
registrar population are certainly associated with lower
scores on the PRU (Cooke, Doust & Steele 2017), but it is
unclear how much of this attenuation of PRU scores may be
due to educational intervention rather than amount of inpractice experience. It is certainly proposed that more
functional responses to uncertainty can be taught within
educational programs (Danczak & Lea 2018; Domen 2016;
O’Riordan et al. 2011; Taylor et al. 2018; Wray & Loo 2015).
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
26
Magin et al.
Particular educational methodologies have been proposed to
develop tolerance of uncertainty. For example, this
includes small group structured exercises designed to
promote reflection (Danczak & Lea 2018). Educational
methodologies have also been proposed to facilitate
teaching (e.g., ‘tactical decision games’ [Drummond et al.
2016]) and assessment (e.g., script concordance testing
[Lubarsky et al. 2013]) within the context of clinical
uncertainty.
GP supervisors are identified as having a vital role in
education around management of clinical uncertainty
(O’Riordan et al. 2011; Sturman, Jorm & Parker 2020). It
has also been proposed that assessment of learners’ level
of responses to uncertainty (using the PRU) would
facilitate education to enhance tolerance of uncertainty
(Wray & Loo 2015). Even in the absence of individual–
registrar-level information, our previous findings (Cooke,
Doust & Steele 2017) on the demographic ‘phenotypes’ of
registrars with higher levels of affective responses to
uncertainty may inform educational approaches.
We have established a role for ‘affective’ responses to
uncertainty
in
registrars
electing
to
access
inconsultation advice and assistance. Further research is
required to explore the role of uncertainty within the
‘social space’ of the resulting registrar–supervisor
interaction (Brown et al. 2018) and to define the role of
supervisors in registrars’ functional adaptation to
clinical uncertainty (including how best to support and
train supervisors in this role). There may be a role for
research examining supervisors’ affective responses to
uncertainty and how this influences the interactions of the
supervisor–registrar dyad. Research could also establish
if educational interventions can reduce ‘anxiety’ and
‘concern’, and what effects this would have on the
registrar–supervisor relationship, including frequency of
advice- or assistance-seeking.
A strength of this study is the linking of valid measures
of registrars’ responses to uncertainty (the PRU subscales)
with
detailed
data
on
registrars’
in-consultation
educational behaviours. The large number of relevant
independent variables measured and the large sample size
of consultations allowed for fine-grained multivariable
analyses. The high response rate, unusual in studies of GPs
(Bonevski et al. 2011), is also a strength.
A limitation is that due to a printing error, complete
data for one of the four PRU subscales were available for
only two rounds of data collection. A further limitation
is that while we have data on how often and for what
problems/diagnoses
registrars
seek
information
or
assistance (and can analyse these in relation to
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
27
Magin et al.
constitutional responses to uncertainty), we do not know
how satisfactorily their seeking assistance addressed their
anxiety or concern in that consultation for that problem.
GP
registrars’
‘affective’
responses
to
clinical
uncertainty are associated with frequency of advice- or
assistance-seeking from their clinical supervisor. The
registrar–supervisor relationship may help registrars
respond functionally to clinical uncertainty, but increased
demands on supervisors related to ‘affective’ response to
uncertainty also create extra work for supervisors.
Acknowledgements
The authors thank the participating registrars and training
practices for their contributions to the ReCEnT project.
Conflict of Interest
A/Prof. Susan Wearne is also an employee of the Department
of Health. The views expressed in this article are her own
and are not necessarily those of the Australian Government.
The other authors report no conflicts of interest.
Funding
The ReCEnT project was funded during the collection of the
data presented in this paper by the participating
educational organisations (General Practice Training—
Valley to Coast, the Victorian Metropolitan Alliance,
General Practice Training Tasmania, and Adelaide to Outback
GP Training Program), which were funded by the Australian
Government. From 2016 to 2019, ReCEnT was funded by an
Australian Department of Health-commissioned research
grant, and was supported by the GP Synergy Regional Training
Organisation. GP Synergy is funded by the Australian
Government.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
28
Magin et al.
References
Alam, R, Cheraghi-Sohi, S, Panagioti, M, Esmail, A,
Campbell, S & Panagopoulou, E 2017, ‘Managing diagnostic
uncertainty in primary care: A systematic critical review’,
BMC Family Practice, vol. 18, article no. 79.
Allison, JJ, Kiefe, CI, Cook, EF, Gerrity, MS, Orav, EJ &
Centor, R 1998, ‘The association of physician attitudes
about uncertainty and risk taking with resource use in a
Medicare HMO’, Medical Decision Making, vol. 18, no. 3, pp.
320–329.
Axelson, C, Wardh, I, Strender, L-E & Nilsson, G 2007,
‘Using medical knowledge sources on handheld computers: A
qualitative study among junior doctors’, Medical Teacher,
vol. 29, no. 6, pp. 611–618.
Bennett, NL, Casebeer, LL, Kristofco, R
‘Family physicians’ information seeking
comparison with other specialties’, BMC
& Decision Making, vol. 5, article no.
& Collins, BC 2005,
behaviors: A survey
Medical Informatics
9.
Bonevski, B, Magin, PJ, Horton, G, Foster, M & Girgis, A
2011, ‘Response rates in GP surveys: Trialling two
recruitment strategies’, Australian Family Physician, vol.
40, no. 6, pp. 427–430.
Bovier, PA & Perneger, TV 2007, ‘Stress from uncertainty
from graduation to retirement: A population-based study of
Swiss physicians’, Journal of General Internal Medicine,
vol. 22, no. 5, pp. 632–638.
Brown, J, Nestel, D, Clement, T & Goldszmidt, M 2018, ‘The
supervisory encounter and the senior GP trainee: Managing
for, through and with’, Medical Education, vol. 52, no. 2,
pp. 192–205.
Clement, T, Brown, J, Morrison, J & Nestel, D 2015, ‘Ad hoc
supervision of general practice registrars as a “community
of
practice”:
Analysis,
interpretation
and
representation’, Advances in Health Sciences Education, vol.
21, no. 2, pp. 415–437.
Conrad, C, Konuk, Y, Werner, PD, Cao, CG, Warshaw, AL,
Rattner, DW, Stangenberg, L, Ott, HC, Jones, DB, Miller,
DL & Gee, DW 2012, ‘A quality improvement study on avoidable
stressors and countermeasures affecting surgical motor
performance and learning’, Annals of Surgery, vol. 255, no.
6, pp. 1190–1194.
Cooke, G, Tapley, A, Holliday, E, Morgan, S, Henderson, K,
Ball, J, van Driel, M, Spike, N, Kerr, R & Magin, P 2017,
‘Responses to clinical uncertainty in Australian general
practice trainees: A cross-sectional analysis’, Medical
Education, vol. 51, no. 12, pp. 1277–1288.
Cooke, GPE, Doust, JA & Steele, MC 2013, ‘A survey of
resilience, burnout, and tolerance of uncertainty in
Australian general practice registrars’, BMC Medical
Education, vol. 13, article no. 2.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
29
Magin et al.
Cottrell, D, Kilminster, S, Jolly, B & Grant, J 2002, ‘What
is effective supervision and how does it happen? A critical
incident study’, Medical Education, vol. 36, no. 11, pp.
1042–1049.
Danczak, A & Lea, A 2014, ‘What do you do when you don’t
know what to do? GP associates in training (AiT) and their
experiences of uncertainty’, Education for Primary Care,
vol. 25, no. 6, pp. 321–326.
Danczak, A & Lea, A 2018, ‘Developing expertise for
uncertainty; Do we rely on a baptism of fire, the mills of
experience or could clinicians be trained?’ Education for
Primary Care, vol. 29, no. 4, pp. 237–241.
Del Fiol, G, Workman, TE & Gorman, PN 2014, ‘Clinical
questions raised by clinicians at the point of care: A
systematic review’, JAMA Internal Medicine, vol. 174, no.
5, pp. 710–718.
Deyo, RA 2002, ‘Cascade effects of medical technology’,
Annual Review of Public Health, vol. 23, pp. 23–44.
Domen, RE 2016, ‘The ethics of ambiguity: Rethinking the
role and importance of uncertainty in medical education and
practice’, Academic Pathology, vol. 3.
Drummond, I, Sheikh, G, Skinner, J & Wood, M 2016,
‘Exploring the feasibility and acceptability of using
tactical decision games to develop final year medical
students’ non-technical skills’, Medical Teacher, vol. 38,
no. 5, pp. 510–514.
Ely, JW, Burch, RJ & Vinson, DC 1992, ‘The information
needs
of
family
physicians:
Case-specific
clinical
questions’, Journal of Family Practice, vol. 35, no. 3, pp.
265–269.
Gerrity, MS, Earp, JL, Devellis, RF & Light, DW 1992,
‘Uncertainty
and
professional
work:
Perceptions
of
physicians in clinical practice’, American Journal of
Sociology, vol. 97, no. 4, pp. 1022–1051.
Gerrity, MS, Devellis, RF & Earp, JA 1990, ‘Physicians’
reactions to uncertainty in patient care: A new measure and
new insights’, Medical Care, vol. 28, no. 8, pp. 724–736.
Gerrity, MS, White, KP, Devellis, RF & Dittus, RS 1995,
‘Physicians’ reactions to uncertainty: Refining the
constructs and scales’, Motivation and Emotion, vol. 19,
no. 3, pp. 175–191.
Gonzalez-Gonzalez, AI, Dawes, M, Sanchez-Mateos, J, RiesgoFuertes, R, Escortell-Mayor, E, Sanz-Cuesta, T & HernandezFernandez, T 2007, ‘Information needs and informationseeking behavior of primary care physicians’, Annals of
Family Medicine, vol. 5, no. 4, pp. 345–352.
Han, PKJ, Klein, WMP & Arora, NK 2011, ‘Varieties of
uncertainty in health care: A conceptual taxonomy’, Medical
Decision Making, vol. 31, no. 6, pp. 828–838.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
30
Magin et al.
Ingham, G, Plastow, K, Kippen, R & White, N 2020, ‘Closer
supervision in Australian general practice training:
Planning major system change’, Australian Journal of
Primary Health, vol. 26, no. 2, pp. 184–190.
Kennedy, TJT, Regehr, G, Baker, GR & Lingard, LA 2005,
‘Progressive independence in clinical training: A tradition
worth defending?’ Academic Medicine, vol. 80, no. 10, pp.
S106–S111.
Kennedy, TJT, Regehr, G, Baker, GR & Lingard, LA 2009,
‘Preserving professional credibility: Grounded theory study
of medical trainees’ requests for clinical support’, BMJ,
vol. 338, b128.
Lubarsky, S, Dory, V, Duggan, P, Gagnon, R & Charlin, B
2013, ‘Script concordance testing: From theory to practice:
AMEE guide no. 75’, Medical Teacher, vol. 35, no. 3, pp.
184–193.
Magin, P, Morgan, S, Wearne, S, Tapley, A, Henderson, K,
Oldmeadow, C, Ball, J, Scott, J, Spike, N, McArthur, L &
van
Driel,
M
2015,
‘GP
trainees’
in-consultation
information-seeking: Associations with human, paper and
electronic sources’, Family Practice, vol. 32, pp. 525–532.
Malterud, K, Guassora, AD, Reventlow, S & Jutel, A 2017,
‘Embracing uncertainty to advance diagnosis in general
practice’, British Journal of General Practice, vol. 67,
no. 659, pp. 244–245.
Morgan, S, Magin, PJ, Henderson, KM, Goode, SM, Scott, J,
Bowe, SJ, Regan, CM, Sweeney, KP, Jackel, J & van Driel,
ML 2012, ‘Study protocol: The Registrar Clinical Encounters
in Training (ReCEnT) study’, BMC Family Practice, vol. 13,
article no. 50.
Morgan, S, Wearne, S, Tapley, A, Henderson, K, Oldmeadow,
C, Ball, J, van Driel, M, Scott, J, Spike, N, McArthur, L
& Magin, P 2015, ‘In-consultation information and advice
seeking by Australian GP trainees from GP trainers: A crosssectional analysis’, Education for Primary Care, vol. 26,
no. 3, pp. 155–165.
Morrison, J, Clement, T, Nestel, D & Brown, J 2015,
‘Perceptions of ad hoc supervision encounters in general
practice training: A qualitative interview-based study’,
Australian Family Physician, vol. 44, no. 12, pp. 926–932.
O’Riordan, M, Dahinden, A, Akturk, Z, Ortiz, JMB,
Dagdeviren, N, Elwyn, G, Micallef, A, Murtonen, M,
Samuelson, M, Struk, P, Tayar, D & Thesen, J 2011, ‘Dealing
with uncertainty in general practice: An essential skill
for the general practitioner’, Quality in Primary Care,
vol. 19, no. 3, pp. 175–181.
Partanen, R 2018, ‘Don’t miss the boat: Maximise ad hoc
teaching
with
general
practice
trainees’,
Medical
Education, vol. 52, no. 2, pp. 143–145.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
31
Magin et al.
Pedersen, AF, Carlsen, AH & Vedsted, P 2015, ‘Association
of GPs’ risk attitudes, level of empathy, and burnout status
with PSA testing in primary care’, British Journal of
General Practice, vol. 65, no. 641, pp. e845–e851.
[‘Erratum’, British Journal of General Practice, 2016, vol.
66, no. 642, p. 15.]
Pekrun, R, Goetz, T, Titz, W & Perry, RP 2002, ‘Academic
emotions
in
students’
self-regulated
learning
and
achievement: A program of qualitative and quantitative
research’, Educational Psychologist, vol. 37, no. 2, pp.
91–105.
Phillips, R & Glasziou, P 2008, ‘Evidence based practice:
The practicalities of keeping abreast of clinical evidence
while in training’, Postgraduate Medical Journal, vol. 84,
no. 995, pp. 450–453.
Schneider, A, Szecsenyi, J, Barie, S, Joest, K & Rosemann,
T 2007, ‘Validation and cultural adaptation of a German
version of the Physicians’ Reactions to Uncertainty
scales’, BMC Health Services Research, vol. 7, article no.
81.
Stanton, N, Francis, NA & Butler, CC 2010, ‘Reducing
uncertainty in managing respiratory tract infections in
primary care’, British Journal of General Practice, vol.
60, no. 581, pp. e466–e475.
Stone, L 2014, ‘Blame, shame and hopelessness: Medically
unexplained symptoms and the “heartsink” experience’,
Australian Family Physician, vol. 43, no. 4, pp. 191–195.
Strout, TD, Hillen, M, Gutheil, C, Anderson, E, Hutchinson,
R, Ward, H, Kay, H, Mills, GJ & Han, PKJ 2018, ‘Tolerance
of uncertainty: A systematic review of health and
healthcare-related
outcomes’,
Patient
Education
and
Counseling, vol. 101, no. 9, pp. 1518–1537.
Sturman, NJ, Jorm, C & Parker, M 2020, ‘With a grain of
salt? Supervisor credibility and other factors influencing
trainee decisions to seek in-consultation assistance: A
focus group study of Australian general practice trainees’,
BMC Family Practice, vol. 21, article no. 28.
Sturman, NJ, Tapley, A, van Driel, ML, Holliday, E, Ball,
J, Davey, A, Fielding, A, Fitzgerald, K, Spike, N & Magin
P 2020, ‘Configurations for obtaining in-consultation
assistance from supervisors in general practice training,
and patient-related barriers to trainee help-seeking: A
survey study’, BMC Medical Education, vol. 20, article no.
369.
Taylor, D, Picker, B, Woolever, D, Thayer, EK, Carney, PA
& Galper, AB 2018, ‘A pilot study to address tolerance of
uncertainty among family medicine residents’, Family
Medicine, vol. 50, no. 7, pp. 531–538.
Thomson, JS, Anderson, KJ, Mara, PR & Stevenson, AD 2011,
‘Supervision—growing and building a sustainable general
practice supervisor system’, Medical Journal of Australia,
vol. 194, no. 11, pp. S101–S104.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
32
Magin et al.
van Der Weijden, T, van Bokhoven, MA, Dinant, G-J, van
Hasselt, CM & Grol, RPTM 2002, ‘Understanding laboratory
testing in diagnostic uncertainty: A qualitative study in
general practice’, British Journal of General Practice,
vol. 52, no. 485, pp. 974–980.
Wallace, E, Salisbury, C, Guthrie, B, Lewis, C, Fahey, T &
Smith, SM 2015, ‘Managing patients with multimorbidity in
primary care’, BMJ, vol. 350, h176.
Wearne, S, Dornan, T, Teunissen, PW & Skinner, T 2012,
‘General practitioners as supervisors in postgraduate
clinical education: An integrative review’, Medical
Education, vol. 46, no. 12, pp. 1161–1173.
White, G & Williams, S 2017, ‘The certainty of uncertainty:
Can we teach a constructive response?’ Medical Education,
vol. 51, no. 12, pp. 1200–1202.
Wray, CM & Loo, LK 2015, ‘The diagnosis, prognosis, and
treatment of medical uncertainty’, Journal of Graduate
Medical Education, vol. 7, no. 4, pp. 523–527.
Health Education in Practice: Journal of Research for Professional Learning, Vol 4, No.
1, 2021
33