What Clinicians Can Learn About Managing Uncertainty: Dr. Jenny Moffett of RCSI University of Medicine and Health Sciences, Dublin

Caleb Furnas: Hi, I'm Caleb Furnas, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. Today, we're going to learn about what's been described as a critical gap in medical education: equipping students to manage uncertainty on the job. 

With us to explain is Dr. Jenny Moffett of the RCSI University of Medicine and Health Sciences, who was recently named Most Innovative Teacher of the Year by Times Higher Education for her work in this area, which includes development of an immersive puzzle game that encourages students to address complex, ambiguous, and unpredictable issues. 

Dr. Moffett is program director of the postgraduate diploma in health professions education at RCSI University of Medicine and Health Sciences in Dublin. Her other areas of interest include psychological safety, universal design for learning, flip learning, and gen AI. Thank you so much for joining us today, Dr. Moffett.

Dr. Jenny Moffett: Well, thanks, Caleb. It's an absolute honor to be here today.

Caleb: Awesome. So I'd like to start with learning more about you and the path you've taken to your current role. I understand you originally were interested in being a veterinarian and a science journalist before heading into academia. What was behind those interests?

Dr. Moffett: Well, yeah, as you've identified, I've had a bit of an esoteric journey into academia. I think like most veterinarians, I was very attracted to a career of working with animals, and I suppose like many, I went through that transition of realizing that once you get into veterinary college and you graduate, it's not just about the animals, it's about the people as well. 

There's a huge amount of psychology and communication and interpersonal skills involved in veterinary medicine and that just really appealed to me. I'm of the age that we didn't actually get any formal training around that, so I did decided to do a masters in science communication and from there just got hugely interested in communication. I suppose with that in learning that when you're working with people it can be quite natural as a doctor or a health professional to think ‘I've got all the answers here, I've got the training, all I need to do is tell this person what to do.’ But as we all know, it's definitely not the reality of it. 

Being able to listen to people, understand where they're coming from, to meet their perspectives and work with them in a person-centered way...that's kind of been at the center of everything I've done in my career. I've carried that through and moving into lecturing and an academic career, I just built off those core values around communication and education.

Caleb: Before we dive into your work on uncertainty, can you describe your overall role at RCSI and what you see as your mission?

Jenny 

Yeah, so I'm a faculty developer and I'm based in HPEC -- the Health Professions Education Centre in RCSI. I have lots of different roles, but I suppose my biggest one is as Program Director for the Postgraduate Diploma in Health Professions Education. That was a course that started out as staff development. RCSI put a huge investment into making sure that their educators are well trained and confident in their skills and so the course was set up to promote that. But then in recent years we've had such a huge interest in it from external students we've actually now got a course that goes out to a wider international cohort. 

Currently I have eighty students on the program from all corners of the globe which I really love because it adds a huge cultural richness and diversity to the group and we're all learning with and from each other as well, so I'm very lucky in my job.

Caleb: That's super cool. Is there anything in particular that you feel like you've learned from these international students around communication and the curriculum? 

Dr. Moffett: Well, everything, everything. I suppose one of the biggest things that we do is we do micro teaching. We have these small groups where they're in a group for the whole length of the program and then at two points in the program, they have to take a ten minute teaching moment and explain or teach a particular topic to their small group. And through that, I've seen so many things. I know a lot about Vasco de Gama, the spice roots, what to put in your compost heap, skin care from a dermatologist. Every year I'm learning something new. 

But again, I think the cultural aspect of it is hugely interesting because when you think about communication and education, there's huge cultural sensitivities around that and there's a lot that we can learn from others around us.

Caleb: For sure. I imagine it's like a really rich set of experiences that you get exposed to. So, describe what you mean by uncertainty in medicine and why you think it is so important to address this with students.

Dr. Moffett: So, uncertainty, was my side gig. Aside from the faculty development, I just become very interested in this topic. There's many different definitions around that. The definition that I used in my doctoral work was that it is a subjective sense of ignorance -- not knowing about something, but also knowing that you don't know -- and it's very much about your response to a situation. I think sometimes people think uncertainty is the situation itself, but there's a huge bank of work that will take the perspective that it's the responses to, and the emotional reactions or cognitive reactions to, those situations that is the phenomenon of uncertainty.

Caleb: Got it, and what pieces of this do you think are generally overlooked in medical education?

Dr. Moffett: I think all of them, Caleb, to be honest with you. I suppose you might ask why do we not talk about uncertainty in medicine? Well, there's definitely been scholars that have been looking at that for decades. There's a sociologist, Renee Fox, who's very famous for carrying out ethnographical work looking at the culture of certainty and uncertainty in medicine, and what she discovered at that time was that there's a culture of certainty, in that everybody craves certainty: the health professionals crave certainty, the patients crave certainty, everybody wants to know an answer. They want it to be black or white. So, there's an inherent unease with uncertainty. 

I think that's why it is one of those topics that people know is there, but don't really bring it up into conscious thought and maybe just kind of let it slip past because they're not quite sure how to grab hold of it and look at it.

Caleb: Right, yeah. I mean, one of the tensions we always saw in our work with faculty from an Osmosis perspective was that there were just some faculty who were really open to this idea of ‘I don't know everything, I'm going to use resources, I’m going to work through problems out loud in front of other students.’ Then there were some faculty who were really nervous or just resistant to that posture. 

So I was wondering, in your work, just on the faculty development side of things, have you had many experiences where faculty were able to become more comfortable with uncertainty and making it more part of their pedagogical approach? Or is it something kind of hardwired and something that people are really loathe to give way?

Dr. Moffett: So with uncertainty, if you look at it, we are in general biologically hardwired to look at uncertainty as something that is uncomfortable and potentially aversive. It comes back to that analogy of prehistoric man and the saber-toothed tiger. If something's rustling in the bushes, we're going to react to that and say, you know, that's not the usual, that's not the norm, let's inspect it or...well actually let's just run away from it! So we're hardwired to scan for things that are just not adding up. You can actually see that in babies and how they respond with regard to stimuli around them. There's some studies that look at early childhood development in which babies scan for uncertainty. So it is hardwired within us. 

But what we are seeing in the research over the last couple of decades is that uncertainty is actually a modifiable domain, whereas in the past it was very much viewed as almost like a personality trait or a type of personality -- so you were tolerant of uncertainty or you're intolerant of uncertainty. But now we know it is something that we can train for. We're still not exactly sure how to train for it and that's why it's really important that people keep doing work around it, but approaches to uncertainty can be learned. We can change our perspective and perceptions around uncertainty, stepping away from always viewing it as something aversive, but perhaps maybe looking at it with a little bit more curiosity and openness, and that's definitely a transformation that faculty can make.

Caleb: My sense of the challenge for some of the faculty is that they feel like they can't be both open to uncertainty and be considered a full expert on something. How do you see that kind of tension or is expertise under assault if you open up the door to uncertainty?

Dr. Moffett: It's a great question and I'm seeing that from two levels, in that there's the uncertainty that you might face -- your personal uncertainty about a case or a patient in front of you -- but also in communicating uncertainty to the patient. I suppose that's maybe a kind of a simpler example in that in your head you want to say to the patient, “We've done tests, we've taken your history, and we still don't know what it is. But you can't turn to the patient and say, “Haven’t a clue. I'm lost.” That's not going to go down well. 

So, you can communicate it in a way that still, I suppose, preserves the relationship and preserves the trust between yourself and the patient. A lot of that is in the communication style. But I do believe you need to be open and honest and transparent with that patient in such a way that they understand the limitations of what the diagnostics have revealed and what the different pathways are. I suppose just working with the patient to say, “I'm on this journey with you, I don't have all of the answers, but certainly we have paths, we have options, and I'll be there with you as we work them out.”

Caleb: Do you give any concrete pointers to students around this, about how they can be better at navigating uncertainty versus expertise in their relationships with patients?

Dr. Moffett: Yeah, I think when it comes to uncertainty, the first and number one thing is to notice that it's uncertainty if you engage with some of the things that happen with it to you in your daily life. You might just say, this happened and I'm so stressed about it. I can't believe they're sending me over to this new team, or I've applied for a job and I don't know what the response is going to be. People might just immediately knee-jerk to say, “I'm really stressed about that. I'm feeling anxious about that.” 

Whereas if you put in an interim step and say, okay, what about this situation might be provoking anxiety for me? And you say, well, you put in for a job and yes, you don't know the answer, you don't know what the response is and a lot may be hanging on it. But the feelings are coming up. They're not stress related to not getting the job, these are actually uncertainties rising up. If you can find a way of just being able to sit with that uncertainty and recognize that it's just about not knowing -- it's not about you've had a bad outcome, you're just sitting with that uncertainty -- that reframing can actually step you back from moving into a stressed place. 

I think it's very knee-jerk for all of us, not just students, to say, I'm feeling stressed or anxious about something. But if they roll back and they can actually label that as uncertainty and have some techniques for sitting with that uncertainty or ways of managing it, that can help. Some people will say, “I can go and research it. I can go and ask for information. I'll try and close down the uncertainty.” But that can backfire on us as well. As anybody who's Googled their health symptoms will know, sometimes seeking information is not actually going to close down that uncertainty for you. 

So just to kind of summarize on that, noticing uncertainty and then maybe taking some space out to reflect on that either individually -- maybe by journaling or kind of just talking it out through use of audio diaries or just record voice notes on their phone or sharing it with a friend as well -- shared reflection is a really good way to unpack uncertainty. And what happens is you sometimes take this monolithic issue that seems pretty impenetrable and you actually unpack lots of smaller uncertainties, some of which you can work with and some you just have to park. But being able to reflect on it can help you actually diffuse some of that anxiety from it.

Caleb: It sounds almost like this is part of a larger project of helping students become self-aware. Is that a fair way to say it, and is that a skill that you're really able to transfer? Back to this question of like nature versus nurture, it seems like some of your med students are probably more able to name their uncertainty and to sit with it and some are some less so. In our daily lives, we run across all kinds of doctors who have varying levels of, for lack of a better word, emotional intelligence around that sort of thing. Do you feel like that's something you can really help students develop that aren't inclined to it? Or what's the challenge like?

Dr. Moffett: Well that's another PhD in that one I think. I don't know enough about it but what I would say is yes. All of the cohort I work with on the diploma go through reflective teaching portfolios. So over the years, I've basically engaged with thousands of reflective portfolios and I can totally see that there are some that find reflective practice and delving into those dimensions of self-awareness much easier than others. 

I'm confident that pretty much everything is a learnable skill. I know that's a huge sweeping statement, but I think when it comes to self-awareness, that can be developed. I suppose what it might be is harnessing the motivation for self-awareness. I used to have a training business around communication skills and I remember talking to a veterinarian about empathy and active listening. I remember she said, “Yeah, I know what I'm meant to do, but that particular client has me so angry and annoyed, I don't want to do any of it. I really don't, they've annoyed me so much I’m past empathy and past active listening.”

It was a bit of a transformation for me in that a lot of my training then started to incorporate, what's the motivation for yourself? So it's not just about empathizing and active listening to support patient or client outcomes, but it's also for your own self-care as well. Because if you're engaging with somebody and they're angry, you're getting angry, you have to swallow some difficult emotions or, you know, regulate some difficult emotions. 

Having said that, if you learn how to engage in empathizing for the right reasons and in the right way, then it's a win-win for you and for the client as well. So I suppose when it comes to self-awareness, I think the key is to hook that into real gains for that health professional so that they can see what self-awareness is doing for them.

Caleb: Yeah, figuring out the motivation and people's incentives is key for this. We find that in just trying to get people to do educational things that we think are relatively fun, but it's always hard, and the motivation has to be furnished somehow. So it makes a lot of sense that if you can help them see that it's in their own psychological best interest to become self-aware, it would seem to be like a win-win. 

Dr. Moffett: Yeah, the intrinsic motivation.

Caleb: Awesome. Yeah, so just getting back to some of your work around gaming, I'd love to hear more about the immersive puzzle game called The Hidden Hospital that was cited by the judges of the award you received. Can you tell us about that?

Dr. Moffett: Yeah...so escape games. This is an online digital educational escape room and it stems from a project that I carried out with students at RCSI. So, around the time the pandemic was hitting the planet, we all moved, as most institutions, into online teaching. I had been involved in online teaching for a long time with my training business, so I was happy enough to move into Zoom and Teams and all of that good stuff. But, I felt there wasn't a lot of engaging online learning there and I thought that we could do it a little bit better. 

So, on one hand, I was just embarking on a PhD around uncertainty. On the other, I wanted to do something that was a little bit more active learning. I was very lucky to put in, and the students put in, for a research grant. We got a small amount of funding from the Irish Network of Healthcare Educators and the Medical Council of Ireland and that allowed us to build this escape game using a design-based research approach to the overall project and then a design thinking strategy to actually build the game itself. 

So between myself and the students, there were ten of us from across three different continents...the Middle East, Europe and the Americas. We never met in person, but we managed to actually bring this game together and prototype it and test it. And, you know, we were very proud of the game that came out of it. 

Now, when I talk about an escape game, people sometimes think of production values like you find in Call of Duty or Fortnite or something like that. But actually, we use a platform called Genially, which is an interactive learning resource. It's basically very much like a fancy PowerPoint and it allows you to go in and include simple visual elements, sound elements, and then have a branching logic. 

So, you come in, you put your puzzle in, you can have your hint strategy, you can have your videos. Then the learners come in, they solve the puzzle, and then they pick which path. It's almost like ‘choose your own adventure’ and then they move on. We use game-based learning elements. We have tokens and so as you go through the learning journey, there are areas for them to kind of like engage with the material and get a reward. But I think the real magic in it is not just the game itself, but as with any kind of simulation, it is in the debrief at the end. 

Say, for example, we have fifty students. We put them into a Teams room, we explain the game and we explain that the puzzles are all aligned with three dimensions of uncertainty and those are ambiguity, complexity and probability which comes from Paul Han et al.'s taxonomy of uncertainty. Then we let them loose. We put them into random groups so they're working with students that they've never met before and off they go into their rooms.  

I'm not in the room with them but I can keep the Teams’ chat channel open and a lot of them choose to engage with each other through the team chat channel so I can actually monitor what's going on in a quiet method. I'm not intruding, but I'm there for them and they know that they can come out. I'm the games master. If they're having a problem, they can signpost and I'll go in. 

They play through the game. It's a race against the clock rather than a race against each other because we want it to be as collaborative as possible. And yeah, so I just love watching the chat channel. It's so funny because they completely forget you're sitting there and it's student to student speak. You can see the emoticons and the “wows” and the “nos” and the highs and the lows are unfolding in the chat channel. 

But ultimately what they're doing is engaging with uncertainty and it's not just the uncertainty of the puzzles. It's the uncertainty of working with people they've never met before. It's the uncertainty of speaking up and sharing their ideas if they don't feel comfortable about that. And those uncertainties are not directly the same as what you would have in clinical practice, but they do mirror some of them, like working with unfamiliar people, collaborating, and really crucially, looking at a problem together. 

There's a couple of the puzzles -- and the student design teams should take credit for this – where you can see them and you know they're looking at it and they're scratching their heads and they're like, “I have no idea. This one is insolvable.” And then all it takes is for somebody to say, “What's that thing up in the top left” Is that anything?” And then somebody else comes in and goes, “Yeah, could that be linked to the…” You can see it and they get really excited and it all comes together. 

So in the debrief we focus on how did the team solve the issues or how did you work together? It's engaging in this idea that, you know, if you're on your own and you have an uncertainty and it feels very personal and it feels impenetrable, to talk about that with somebody else, they can oftentimes see a completely different perspective on it. And so that shared reflection can really help them to unpack the uncertainty, see it from a different angle, and then they can take those kind of transferable skills out with them into clinical practice.

Caleb: That's amazing. It seems like a really useful exercise for any number of students just to have that kind of muscle memory about what it's like to work in a team with uncertainty. That's great. I would love to do something like that. I've done escape rooms with my own colleagues and my own children, and there's an element of after the fact, you all kind of debrief, even informally and it's really fun. 

You know, we have many students and early career health professionals in our audience. What's your advice to them about meeting the challenges of this moment and approaching their career in health care? And it can relate to uncertainty or not, but we'd like to just sort of put this out as an open question to our educators.

Dr. Moffett: Well, for this one, I think in working with my learners on the diploma, one bit of the job that I really love is being hopefully a positive influence in people's careers. I suppose one of the key things I would say is it’s really important to understand your values and your strengths. I'm also a trained life coach and I talk a lot about being able to identify what those values are and revisit them and go back to them. I know a lot of people might go out and do a values exercise, but it’s important to check in and do a pulse check with yourself on a regular basis to see if what I'm doing is aligned with my deep, core values. 

For me, it's communication and education, but also having work that is meaningful. I'm very lucky in the role that I'm in. It's a very fast pace. There's lots of different projects, but most of them align with communication and education for me. So, even though it's a busy job, I get a lot of sense of joy and meaning from what I do.

I think for those going out into health professions practice, it can be very challenging. Certainly, I know a lot of health services around the world are under pressure at the moment, and it can feel very draining and it can feel relentless. But if you can fit in things that bring you meaning into your work, however small, just to give you that sense of an anchor that you're on the right path. And if you aren't finding ways of actually securing that meaning, then you really need to rethink, you know, are you in the right job? Are you on the right track at the moment? So I think finding meaning in your work, and if you can't find that, then you have to appraise and reflect and maybe ask for advice on what to do with that.

Caleb: That's great, and frankly, very candid. You hear all kinds of advice for students and there's so much of a grind mentality. So I really appreciate that. I think it's really insightful. 

Well, thank you so much, Dr. Moffett, for being with us today. I'm Caleb Furnas. Thanks for checking out today's show. Remember to do your part to raise the line and to strengthen the healthcare system. We are all in this together.