By: Vera P. Luther, MD, assistant professor, Department of Internal Medicine/Infectious Diseases, Wake Forest University School of Medicine

My family has a tradition of working together on jigsaw puzzles during holidays and summer vacations. It’s a fun activity that involves teamwork. We enjoy the discovery of interesting shapes and making connections between pieces and groups, but it’s hard to deny that certain satisfaction in placing the last piece of a jigsaw puzzle, a special honor reserved for the youngest member of the family. The practice of medicine and working with people, each wonderfully complex and unique, has many similarities with working on jigsaw puzzles. In some ways, placing the last piece of a jigsaw puzzle is analogous to making a diagnosis. Interestingly, the statement, “The best part of working on a jigsaw puzzle is putting in that last piece,” is one of seven items on the Tolerance for Ambiguity (TFA) scale. An affirmative answer indicates a lower TFA for that item.

In their article “Ambiguity Tolerance of Students Matriculating to U.S. Medical Schools,” Caulfield et al. report on the results of a TFA scale from 13,867 entering medical students and note that higher TFA scores were associated with male gender, older students, and an expressed desire to work in an underserved area. Lower TFA scores were associated with higher perceived stress levels. The authors should be commended for their work involving such a large sampling of medical students across the country. And, as with most important studies, the article brings to light more questions than it answers. Some of these questions would be helpful in determining how TFA should be incorporated into medical school admissions criteria or medical education. For example, to what extent are psychological constructs such as TFA stable over time among medical students, residents, and practicing physicians? To what extent can students or physicians be taught to increase their TFA? Could the anxiety associated with a lower TFA be harnessed or focused into a productive venue and actually provide motivation for discovery?

While existing data might suggest that a lower TFA is a negative trait (associated with increased resource utilization, decreased compliance with treatment guidelines, fear, discomfort, and higher rates of burnout), I wonder whether there are positive aspects to this trait. Intuitively, it seems that some discomfort with uncertainty is healthy. After all, doesn’t this discomfort drive us to find meaning, confirm a difficult diagnosis, describe a new medical condition, innovate, and invent? If uncertainty were perfectly comfortable, this motivation may be absent. While there is some data on TFA and its association with specialty choice, it would be interesting to determine whether physicians with a lower TFA might not only choose certain specialties, but also actually excel in certain areas of that field. For instance, the ability to quickly categorize illness scripts might be advantageous in specialties where rapid decision making is essential, such as in emergency medicine.

There are still many unanswered questions on TFA, but existing data would suggest that TFA is an important psychological construct that has beneficial qualities. Thus, medical educators should be encouraged to incorporate techniques to increase TFA, and ideally, study the impact of these techniques on TFA. The incorporation of techniques such as Motivational Interviewing into medical education may be one strategy to increase TFA as students learn how to effectively navigate the complexities of decision-making, behavior change, and the patient-physician relationship. Another approach may involve educational exercises that enhance a student’s medical decision making sophistication to: (1) accept that there isn’t a solution to every problem, (2) consider contradictory information without dismissing it, (3) avoid drawing conclusions too quickly, and (4) avoid worrying about explaining every detail (without missing important ones). Role-modeling and discussing methods to find joy in the processes, not just in the outcomes, of providing clinical care may be another effective tool.

Until we know the full role of TFA in clinical care, I will continue to enjoy seeing the last puzzle piece get snapped into place.