Characterizing Tolerance of Uncertainty Among Pediatric Hospitalists

Background: Within institutions, individual pediatric hospitalist physicians demonstrate variation in clinical practice. While the drivers of practice variation in the pediatric inpatient setting are poorly understood, physician tolerance of uncertainty is likely to impact clinical decision-making. In other physician specialties, lower tolerance of uncertainty has been associated with psychological distress, burnout, and increased utilization of diagnostic tests and new medical interventions. However, tolerance of uncertainty has not been characterized among pediatric hospitalists.

Methods: We distributed an electronic questionnaire using REDCap to the 102 pediatric hospitalists in the Section of Hospital Medicine at the Children’s Hospital of Philadelphia between March 3 and April 11, 2021. The questionnaire included the validated revised Physicians’ Reactions to Uncertainty (PRU) scales, which consist of 15 total questions scored on a Likert scale and assess physician tolerance of uncertainty across 4 domains: Anxiety Due to Uncertainty, Concern About Bad Outcomes, Reluctance to Disclose Uncertainty to Patients, and Reluctance to Disclose Mistakes to Physicians. The questionnaire also inquired about demographic characteristics, residency training background, attending clinical experience, and percentage of full-time effort (FTE) in frontline and supervisory attending roles. Two-tailed Student t-tests were used to compare mean PRU scores by clinical and training characteristics, with findings considered statistically significant at p<0.05.

Results: 95 pediatric hospitalists participated in the survey (93% response rate). The majority of hospitalists identified as female (74%) and White Non-Hispanic (74%). Hospitalists demonstrated the greatest variability in scores on the Anxiety Due to Uncertainty and Concern About Bad Outcomes scales (Figure). Hospitalists with 6-10 years of attending experience demonstrated lower Anxiety Due to Uncertainty scores than hospitalists with 0-5 years of attending experience, p=0.03 (Table). There were no other differences in PRU scores by attending clinical experience, training background, percent FTE in a frontline or supervisory attending role, or total clinical FTE as a ward attending (combined frontline and supervisory attending roles).

Conclusion: In a large sample of pediatric hospitalists at a single institution, tolerance of uncertainty varied widely for scales measuring Anxiety Due to Uncertainty and Concern About Bad Outcomes. Pediatric hospitalists with 6-10 years of experience had modestly lower Anxiety Due to Uncertainty scores compared with attendings with 0-5 years of experience, but there were no other associations of clinical or training characteristics with tolerance of uncertainty. Our findings support existing literature that tolerance under uncertainty is a highly personal characteristic that may differ between individuals within similar practice settings. Limitations of this study include the point prevalence design, which precludes understanding of how tolerance of uncertainty may evolve over time, as well as limited generalizability beyond a single institution. Future directions include associating tolerance of uncertainty with patterns of clinical practice, resource utilization, and diagnostic error among pediatric hospitalists.