The Experience of Uncertainty amongst Doctors working within Primary Healthcare in Malta

Introduction

Uncertainty is inherently a major constituent of primary healthcare, sometimes even being referred to as one of the biggest hurdles the family doctor faces daily.¹ Uncertainty can be a significant source of stress and anxiety to both doctor and patient and indeed, trainees in family medicine are often advised to accept uncertainty as an inevitable part of primary healthcare.

However intolerance to uncertainty among both the primary care physicians and their patients can affect the medical decision-making process, as doctors may feel pressured to uncover illness at the earliest whilst patients may demand more investigations, despite the doctors’ awareness that excessive testing and referrals may be harmful, beyond medical guidelines and evidence.² An inability to manage uncertainty in family practice well can lead to longer consultations and professionalism issues.³

Intolerance to uncertainty in primary care physicians has also been associated with burnout and low compassion satisfaction⁴, thereby having negative effects on doctors' wellbeing during work hours, but potentially even in their personal lives. In a Maltese study by Baldacchino and Abela intolerance to uncertainty and challenges in its management were found to discourage foundation doctors from continuing their careers in family medicine.⁵

It is therefore worth comprehending the characteristics and factors which increase such uncertainty in family medicine, to address it and subsequently improve the primary healthcare service to patients.

Although this subject has been the basis of many qualitative literature and research, fewer quantitative studies have been produced. Quantitative data may be able to better demonstrate the magnitude of uncertainty in family medicine and has better comparability.

This is a retrospective cross-sectional observational study, with the aims of assessing the experiences of uncertainty in doctors practising in primary healthcare in Malta and identifying factors which increase such uncertainty, as well as strategies used to manage it. In so doing, this study may also indicate which subgroups of doctors experience more uncertainty, and who are possibly using maladaptive measures to try tackling uncertainty in their practice.

This information can be used to improve healthcare systems in family medicine, as doctors and patients can be supported further.

Materials and Methods

Study Setting

Primary healthcare in Malta is split in two sectors – public and private. In the national tax-funded public sector, ten primary health centres and other smaller district clinics are currently operating throughout the Maltese islands.⁶ The services of family doctors are mainly available through walk-in and only recently, in certain instances, by prior appointment.

Family doctors practising in the private sector are more widespread throughout the islands and may serve at their own or at a pharmacy clinic. However they often operate alone and unlike in the public sector, clinical notes and IT systems used in tertiary healthcare may not be available.

In 2007, the Specialist Training Programme in Family Medicine (STPFM) was launched for junior doctors wishing to specialise in family medicine, with the aim of “focus[ing] on the learning needs of family medicine”, through a three-year programme overseen by trainers in family medicine and supervisors during hospital placements.⁷

Study Design and Participants

To gather data, an online questionnaire was created using Google Forms. The questionnaire was written in British English. To avoid missing data, all question fields were marked as mandatory to answer.

The questionnaire was split into four sections:

• demographic data
• the revised physician reaction to uncertainty (rPRU) questionnaire
• factors contributing to uncertainty in family practice
• strategies used to manage such uncertainty

Statements were designed as closed questions, however in the third and fourth sections, participants had the option to elaborate further through free text. The full questionnaire is included in Digital Supplementary File 1.

This questionnaire was sent to the principal general practitioners of health centres in Malta and was then distributed by email to all doctors employed in their respective primary care institutions, together with an invitation to participate. The questionnaire was also sent to members of the Malta College of Family Doctors’ Google group, which includes family doctors exclusively practising in the private sector. Hence participation was on a voluntary basis only and subjects were recruited only by approaching their respective institutions or associations. All doctors working in primary healthcare in Malta were eligible to participate.

Data was collected between the 13^th and 22^nd March 2021 and was stored and analysed in Microsoft Excel.

This study was deemed exempt from ethics review however participants were told the intention of the study in an invitation letter attached to the questionnaire. A contact email address was also provided to potential participants to address any queries. Data remained anonymous and was not shared with third parties.

The demographic data gathered includes gender, age, number of years practising, and professional role. Respondents were also asked whether they practise in the private sector and whether they have undergone or are currently undergoing the STPFM in Malta.

In the second section, the rPRU questionnaire was implemented, a copy of which is also provided in the ‘Supplementary Materials’ section. This is a validated questionnaire developed in 1990 by Gerrity et al to measure physicians’ affective reactions to uncertainty, and later revised in 1995.⁸It presents a total of fifteen statements, divided in four sections – ‘Anxiety due to uncertainty’ (five items), ‘Concern about bad outcomes’ (three items), ‘Reluctance to disclose uncertainty to patients’ (five items), and ‘Reluctance to disclose mistakes to physicians’ (two items). In the revised version of this questionnaire, Gerrity et al group the first two sections as ‘Stress from uncertainty’ and the last two sections as ‘Reluctance to disclose uncertainty and mistakes’. Therefore for simplicity’s sake, this latter arrangement was utilised for this study.

Statements were scaled on a six-point Likert scale, i. e. ‘strongly agree’, ‘moderately agree’, ‘slightly agree’, ‘slightly disagree’, ‘moderately disagree’, ‘strongly disagree’, wherein each response in the Likert scale for each of the fifteen statements was scored differently. Scores of the two main sections of the rPRU questionnaire, i. e. ‘Stress from Uncertainty’ and ‘Reluctance to Disclose Uncertainty and Mistakes’, as well as their total, were calculated for each respondent. Higher scores indicated higher levels of stress from uncertainty and/or increased reluctance to disclose uncertainty and mistakes.

Mean scores and variances were then calculated, as needed. Hypothesis testing was carried out in Microsoft Excel. Statistical significance was set at a probability (p) value of less than 0.05.

The t-test of independence was used to compare mean scores of the rPRU questionnaires between male and female respondents, between trainees (foundation doctors and trainees in family medicine) and their seniors (family doctors, senior family doctors and principal family doctors), between doctors practising in the public sector and those practising in the private sector, and between doctors trained or currently undergoing training with the STPFM and those not trained with the STPFM

Single-factor ANOVA hypothesis testing was employed when comparing variance between doctors of ten years or less (≤10) of practicing experience, doctors of eleven to thirty years^11-30 of practicing experience, and doctors with more than thirty years (>30) of practicing experience.

In the third and fourth sections of our online questionnaire, we asked respondents which factors contributed to feelings of uncertainty in their practice and what strategies they used to manage such uncertainty, respectively. Respondents were able to tick more than one box in these sections and had the option of writing free text to elaborate further should they wish to do so.

This study adhered to the STROBE statement guidelines for cross-sectional studies.

Results

A total of 77 respondents completed the questionnaire. The demographic characteristics of the study population are visualised in Table 1.

The total score of the rPRU questionnaire, as well as scores of its two main sections, ‘Stress from uncertainty’ and ‘Reluctance to disclose uncertainty and mistakes’, were compared between groups. Statistical significance at a p-value of less than 0.05 was obtained when comparing ‘Stress from uncertainty’ scores and the total rPRU scores in males and females. This was also the case when comparing ‘Stress from uncertainty’ scores, ‘Reluctance to disclose uncertainty and mistakes’ scores, and the total rPRU scores in trainee doctors and their seniors. Again statistical significance was obtained when comparing ‘Reluctance to disclose uncertainty and mistakes’ scores and the total rPRU scores among groups of doctors with differing years of practice experience.

No statistically significant difference was noted when comparing scores between doctors who practice privately and those in the public sector, and between doctors who were trained or training with the STPFM and those not trained with the STPFM. Results of this analysis can be seen in Table 2.

When addressing factors which contribute to feelings of uncertainty in primary healthcare, most respondents (n = 56, 72.73%), stated ‘ambiguous or vague presentation of illness’ as one such factor which they encountered in their practice.

‘Having separate medical notes between primary care and hospital care’ was the second most agreed upon factor which contributed to uncertainty (n = 47, 61.03%,), whilst ‘lack of continuity of care’ was the third most agreed upon factor (n = 45, 54.44%,).

Asked which strategies respondents use to cope with feelings of uncertainty in their practice, most stated that they ask patients to come for a future review (n = 65, 84.41%,).

64 respondents (83.12%) stated they share decision-making with the patient. 62 respondents (80.52%) stated that they explain red flags and warning signs to patients, whilst 61 respondents (79.22%) stated that they seek to identify patients’ main concerns.

Responses to the third and fourth sections of the questionnaire can be visualised in Table 3 and Table 4 respectively.

Discussion

The Maltese medical council register of family medicine specialists ⁹ has 63.72% male and 36.08% female family doctors currently registered at time of writing. For the sake of comparing like with like, when excluding study respondents who were still in training, 66.13% (n = 41) were males and 33.87% (n = 21) were females. This makes this section of the study population representative for gender.

A considerable proportion of doctors in our study population reported more than 30 years of practising experience (36.4%) while of trainee respondents was proportionally lower totalling 19.5% of the total study cohort. Therefore a representative skew towards senior doctors can be inferred from the study results.

The rPRU questionnaire was used to identify subgroups within the study population who experienced more uncertainty in their practice. Such uncertainty can lead to negative affective reactions within the physicians as measured by the ‘Stress from uncertainty’ scale in the rPRU The physician may also exhibit particular maladaptive behavioural responses to uncertainty, such as an unwillingness to admit uncertainty and misjudgements in patient management and may feel disinclined to discuss and reflect on experiences of uncertainty with colleagues and patients, as measured by the ‘Reluctance to disclose uncertainty and mistakes’ scale in the rPRU questionnaire.

It is well-documented that anxiety, and indeed anxiety disorders ¹⁰, are more prevalent in women. In our study, female doctors were observed to have higher ‘Stress from uncertainty’ scores on the rPRU questionnaire than male doctors, which was statistically significant at p = 0.036. However no statistically significant difference was shown in ‘Reluctance to disclose uncertainty and mistakes’ between genders. This suggests that the female doctors in our cohort felt more stressed in the face of uncertainty in their practice than their male counterparts. However maladaptive responses to uncertainty, with reference to reluctance to disclose uncertainty and mistakes with patients and colleagues, were not associated with gender.

When comparing the total rPRU scores in groups of doctors with different years of practise experience, i. e. ≤10 years, 11-30 years and >30 years, a statistically significant difference emerged (p = 0.018). Similarly comparison of rPRU scores between trainee doctors and their seniors showed statistically significant differences in both the ‘Stress from uncertainty’ and the ‘Reluctance to disclose uncertainty and mistakes’ categories (p = 0.025 and p = 0.025 respectively). This agrees with findings from Cooke et al’s study carried out among Australian trainees in family medicine ¹¹, as well as from Politi et al’s study among primary care physicians ¹²

Experience helps junior doctors to learn skills to deal with uncertainty in medicine. Trainees might be more familiar with seeing the acute phase of illness and are still developing their diagnostic and clinical reasoning skills.³ They can also feel stripped from the reassurance of working in a large team, as they now work more independently in primary care.³ Trainees are generally encouraged to discuss thoughts and concerns with their more-experienced supervisors and seniors, as this in itself serves as a useful tool in dealing with uncertainty¹⁰ as this can help doctors reflect on their patient consultations, identify what should be improved and formulate solutions to do so.

rPRU scores of doctors practising in public and private sectors were also compared using hypothesis testing, however no statistically significant difference emerged. This is despite that private family doctors tend to be more limited in resources, such as restricted access to hospital medical notes and limited investigations, and despite the more solitary environments private doctors usually practise in. This result indicates that the private family doctors in our study population may have developed ways to manage uncertainty and balance any disadvantages they may have compared to the public sector. Such adaptations can be achieved through experience, especially when considering that n = 20 (64.52%) from our total of 31 doctors who practise privately have more than 20 years’ practising experience, as well as other strategies to manage uncertainty which will be discussed later in this section.

Finally when comparing rPRU scores among doctors trained or currently training with the STPFM and those not trained with the STPFM, no statistically significant difference was noted. As the STPFM was launched in 2007, doctors studying before did not have a local specialised training programme available to them. This result implies that these doctors may utilise alternative educational tools to continue and improve their professional development, which help them adapt to deal with uncertainty in their practice.

Uncertainty can be attributed to various interplaying factors. These may be disease-centred, such as presentations which are vague or at the early stages of disease, making diagnosis difficult. Factors contributing to uncertainty may also be patient-centred – for example, patients might prioritise problems differently and have underlying psychosocial and economic challenges which may complicate patient management. They may even be doctor centred. Here inexperience and limited diagnostic and clinical reasoning skills may be concerning especially for trainees.³ The doctor’s personality traits such as neuroticism, may also come into play and further increase stress from uncertainty.¹³

61.04% (n = 47) of doctors in our cohort stated that having separate medical notes between primary and hospital care contributes to uncertainty. In 2020, the electronic patient record (EPR) system for Maltese primary healthcare was launched and is currently utilised in the public sector¹⁴, however its uptake by private family doctors has been less than desirable.

58.44% (n = 45) of doctors stated that lack of continuity of care adds to uncertainty as outcomes of consultations remain unknown. In a Maltese study looking at patients’ experiences in private and public sectors of primary healthcare, Pullicino et al indicated that the private sector offered better continuity of care¹⁵, which is one of the key characteristics of family medicine, as outlined by European Academy of Teachers in General Practice in their definition of general practice.¹⁶As public-sector health centres are manned by different doctors, continuity of care can be challenging especially for walk-in patients. To address this, appointment clinics have started operating in 2021, where patients can make future appointments with the same primary care physician. However patients with urgent complaints who attend public-sector primary health centres would still be seen as walk-in cases by the doctor available at the time.

Lastly in our questionnaire, doctors were asked which strategies they use to manage uncertainty in their practice. 84.42% (n = 65) stated that they recommend patients to come again for a follow-up appointment, thereby maintaining continuity of care. 83.12% (n = 64) stated they share decision-making with patients, taking into consideration their needs and preferences using a non-paternalistic approach. According to the National Institute for Clinical Excellence shared decision-making has the advantage of making sure patients comprehend benefits, harm and possible outcomes of different management options. It also empowers them to make informed decisions about their management.¹⁷

Doctors in our study population also stated that they manage uncertainty by explaining red flags and warning signs to patients (n = 62, 80.52%), they seek to identify patients’ main concerns (n = 61, 79.22%), and they perform safety netting in their consultations (n = 58, 75.32%). These principles are encompassed in the Calgary-Cambridge referenced observation guide, as developed by Kurtz and Silverman in 1996, which delineates skills for effective communication between doctor and patient.¹⁸

Limitations

As recruitment to the study was voluntary, sampling bias may have occurred, especially given the fact that a larger proportion of older family practitioners were present in our study population. The skewed population could have affected data interpretation.

This study assesses the experience of uncertainty in doctors working in primary healthcare and does not explore if and how this uncertainty affects management of the patient’s illness or patient satisfaction with the consultation, as it was not the scope.

Moreover the study population did not only include qualified family doctors (80.5%) but also trainee Family Doctors (15.6%) and 3 (4%) Foundation Doctors who, despite showing interest in Family Medicine might not eventually opt for working in the family medicine specialty.

Conclusion

By means of a quantitative validated tool, this study showed that negative affective reactions to uncertainty were present more among female doctors and among trainee doctors. Maladaptive behaviours in reaction to uncertainty were present among trainee doctors. Better support is needed for primary care physicians to manage uncertainty in their practice, through self-reflection and discussions with colleagues and supervisors, as this may help in coming up with healthy ways of management of uncertainty. Having separate medical notes between primary and hospital care, and a lack of continuity of care can further contribute to uncertainty in family medicine. These can be managed by encouraging widespread use of a centralised electronic patient record system and increasing accessibility of hospital IT systems to doctors in primary healthcare, both in the private and public sectors, to maintain continuity of care and decrease uncertainty. Utilisation of appointment clinics also help maintain continuity of care and may also provide a protected time slot for the doctor-patient consultation.

Further studies could be done to re-assess experiences of uncertainty among specific doctor subgroups after implementation of recommendations to decrease uncertainty in family medicine.

Summary Box

What is already known?

• Uncertainty is frequently encountered in family medicine and it may lead to stress in both primary care physicians and patients.
• Intolerance to uncertainty among both the primary care physicians and their patients can lead to longer consultations, doctor professionalism issues, and affect the medical decision-making process. It has also been associated with burnout and low compassion satisfaction in primary care physicians and was one factor which discouraged junior doctors from continuing their careers in family medicine.
• Qualitative literature and research uncertainty in family medicine have been published, wherein management strategies are also recommended. However fewer quantitative studies have been produced.

What are the new findings?

• Negative affective reactions to uncertainty were present more among female doctors and trainee doctors. Maladaptive behaviours in reaction to uncertainty were present among trainee doctors.
• Ambiguous presentations of illness, having separate medical notes between primary and hospital care, and lack of continuity of care, contribute to uncertainty in family medicine.
• To manage uncertainty in family medicine, doctors encourage patient reviews, share decision-making with patients and explain red flags.
• Further support for doctors is needed to manage uncertainty in family medicine in a healthy manner. Primary healthcare clinics can also help in doing so through centralised national healthcare IT systems and appointment clinics to maintain continuity of care.

References

1. Malterud K, Guassora AD, Reventlow S, et al Embracing uncertainty to advance diagnosis in general practice. Br J Gen Pract. 2017;67(659):244-5.
2. Opdal PO, Meland E, Hjorleifsson S Dilemmas of medical overuse in general practice – A focus group study. Scandinavian Journal of Primary Healthcare 2019;37:(1)135-40.
3. Morgan S, Coleman J Managing Uncertainty in General Practice. Victoria: General Practice Supervisors Australia 2017.
4. Cooke GPE, Doust JA, Steele MC A survey of resilience, burnout, and tolerance of uncertainty in Australian general practice registrars. BMC Med Educ 2013;13:2.
5. Baldacchino M, Abela J A study on the attitudes of foundation doctors in Malta towards general practice and their experience while working in the specialty. Journal of the Malta College of Family Doctors 2018;7:(2)6-14.
6. Government of Malta. Primary HealthCare. health.gov.mt. Published 2021. Accessed July 20, 2021. https://deputyprimeminister.gov.mt/en/phc/Pages/Home.aspx.
7. Government of Malta. Specialist Training Programme in Family Medicine. health.gov.mt. Published 2021. Accessed July 20, 2021. https://deputyprimeminister.gov.mt/en/phc/stpfm/Pages/Specialist-Training-Programme-Family-Medicine/stpfm.aspx.
8. Gerrity MS, White KP, DeVellis RF, et al Physicians' Reactions to Uncertainty: Refining the constructs and scales. Motiv Emot 1995;19:175-91.
9. Government of Malta. Medical Council Registers. health.gov.mt. Published 2021. Accessed October 7, 2021. https://deputyprimeminister.gov.mt/en/regcounc/medicalcouncil/Pages/Registers.aspx
10. O'Riordan M, Aktürk Z, Bueno Ortiz JM, et al Dealing with uncertainty in general practice: an essential skill for the general practitioner. Qual Prim Care 2011;19:(3)175-81.
11. Cooke G, Tapley A, Holliday E, et al Responses to clinical uncertainty in Australian general practice trainees: a cross-sectional analysis. Med Educ 2017;51:(12)1277-88.
12. Politi MC, Legare F Physicians’ reactions to uncertainty in the context of shared decision making. Patient Educ Couns 2010;80:(2)155-7.
13. Schneider A, Wubken M, Linde K, et al Communicating and Dealing with Uncertainty in General Practice: The Association with Neuroticism. PLoS One 2014;16:9:(7)e102780.
14. Government of Malta. Electronic Patient Records. health.gov.mt. Published 2021. Accessed June 30, 2021. https://deputyprimeminister.gov.mt/en/phc/Pages/Services/Electronic-Patient-Records/Electronic-Patient-Records.aspx.
15. Pullicino G, Sciortino P, Calleja N, et al Comparison of patients’ experiences in public and private primary care clinics in Malta. Eur J Public Health 2014;25:(3)399-401.
16. Allen J, Gay B, Crebolder H, et al The European Definition of General Practice / Family Medicine. Wonca Europe. 2005. Accessed July 11, 2021. https://www.woncaeurope.org/page/definition-of-general-practice-family-medicine.
17. National Institute for Health and Care Excellence (NICE). Shared decision making. Accessed July 31, 2021. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/shared-decision-making.
18. Kurtz SM, Silverman JD The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Med Educ 1996;30:(2)83-9.

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