Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.

AIM:The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care. BACKGROUND:The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role. METHOD:A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data. FINDINGS:Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty. CONCLUSION:This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.