编者注：在临床实践中，经常会遇到很多未知的因素，或者某些病例，在诊断和治疗过程中，需要做决策的时候，骨科医生并不那么自信，或者拿不准，连骨科医生也不知道该咋做。而作为患者，他们需要一个知识全面，自信果敢的骨科医生来给他们做治疗，增强患者自身对采取治疗的信心。

我们从未对此进行关注，在貌似自信果敢的骨科医生决策后面，是否还有未知的因素影响着他们的决策，以及他们自信果敢的表面下是否掩饰着他们的不自信，不确定，和拿不准？？

如何证明骨科医生愿意承认他们的未知，他们的不自信，他们的不确定，他们的拿不准？

最近读到一篇文献，真就对这方面进行了调查研究，特翻译出来，以供大家参考和交流。

摘要

背景：骨科的许多决策都建立在不确定的证据之上。因此，不确定性是我们日常工作的一部分，然而医生对治疗的不确定性可能会有损患者的健康。目前尚不清楚医生的不确定性是否具有独立证据之作用，或还包括其他因素。随着经验的增加，不确定性有望减少，但可能更有影响力的是医生的信心，对所发表内容真实性的信念，甚至一个人的宗教信仰。此外，有理由相信，医生所从事的执业类型可能会影响不确定性体验。执业医生在做临床决策时，可能不会即刻意识到经历这种不确定性的影响。

问题/目的：我们问：(1)不确定性和过度自信的偏倚是否会随着执业年限的增加而减少？(2)哪些社会人口统计学因素独立地与人们对不确定性(特别是对上帝或其他神的信仰)的认可度较低相关，无神论与对不确定性的认知度有何关联？(3)自信心偏倚(相信自己的技能比实际水平更高)、对骨科循证的信任程度以及统计学的复杂程度是否与对不确定性的认知度独立相关？

方法：设计调查问卷，对不确定性得分(4个问题)、骨科循证的信任度(4个问题)、自信心偏倚(3个问题)和统计学理解(6个问题)进行调查。研究人员联系了差异科学组(SOVG)的706名成员，以完成我们的调查。差异科学组旨在研究人类疾病定义和治疗中的差异。本组成员主要为专门从事创伤或手腕外科的骨科医生，执业地多在欧洲和北美，其中大多数人从事教学工作。大约近一半的医生工作10年以上。242名成员(34%)完成了调查。我们发现应答者和无应答者之间没有区别。每个调查项目都比其他任何一个项目更好地衡量了自己的特质。不确定性认知(0.70)和自信心偏倚(0.75)具有相对较高的Cronbachα水平，这意味着构成这些特质的问题密切相关，可能度量相同的结构。这在统计学理解(0.48)和对骨科循证的信任(0.37)方面较低。随后，结合每个特质的单独问题，我们计算出每个特质的0到10分。不确定性认知的平均得分为(3.2±1.4)分。

结果：日常实践中对不确定性的认知并不随执业年限的变化而发生改变(0-5年，3.2±1.3；6-10年，2.9±1.3；11-20年，3.2±1.4；21-30年，3.3±1.6年；p=0.51)，但过度自信偏倚与执业年限相关(0-5年，6.2±1.4；6-10年，7.1±1.3；11-20年，7.4±1.4；P=0.51)。21-30年，7.1±1.2年；p<0.001)。考虑到多变量分析中变量之间的潜在相互作用，与学院派执业相比，对不确定性的独立认知较少，但与多专业组的工作联系较弱(b回归系数，-0.53；95%可信区间 [CI]，-1.0 to-0.055；部分R2，0.021；p=0.029)、信仰上帝或任何其他神(b，-0.57；95% CI，-1.0 to-0.11；部分R2，0.026；P=0.015)，更大的自信心偏倚(b，-0.26；95% CI，-0.37 to-0.14；部分R2，0.084；p<0.001)，以及对骨科循证的更大信任(b，-0.16；95% CI，-0.26to -0.058；部分R2，0.040；p=0.002)。更好的统计学理解与更大的不确定性认知具有独立的，更强的相关性。(b，0.25；95% CI，0.17-0.34；部分R2，0.13；p<0.001)。

我们的整个模型占不确定性认知可变性的29% (调整后的R2，0.29)。

结论：骨科医生相对较低的不确定性水平和自信心偏倚似乎与缺乏确凿证据不一致。如果患者希望了解与他们的诊疗相关的不确定性范畴和外科医生之间的差异，那么对不确定性的低认知和外科医生的自信心偏倚可能会妨碍充分告知患者、知情同意和决策。此外，对不确定性的有限认知与可修改的因素有关，如自信心偏倚、对骨科循证的信任以及对统计学的理解。也许，改进住院医师的统计学教学、建立期刊俱乐部以提高对证据的评判和对偏倚的认知，以及在课程和会议上承认知识差距，都可能会提高人们对现有不确定性的认知。

证据级别：1级，预后研究。

前言

骨科的许多决策都建立在不确定的证据上。设计良好的随机对照试验经常显示两种治疗方法之间没有差异或很小且可能不重要的差异[8，19]。临床证据[3]目前将3000种常见治疗方法中的50%归类为“疗效未知”，只有11%归类为已证实有效(其余24%可能有效，7%疗效利弊持平，5%不太可能有效，3%可能无效或有害)。虽然缺乏证据似乎是日常实践的一部分，但医生对治疗的不确定性可能会有损患者的健康，因为许多人会向他们的医生寻求自信的指导。据我们所知，医疗机构对与日常骨科实践相关的问题(什么可以，什么不可以)的不确定性的感知程度尚未评估过。随着外科医生获得经验，他们以前认为不确定的事情变得不那么确定，这似乎是有道理的。

随着外科医生经验的获得，会减少他们以前的认知不确定性。对不确定性的认知也可能受到许多其他个人因素的影响。一些报告表明宗教信仰[1，21，24]和过度自信是重要因素[7，25，26]。由于证据可能取代不确定性，对已发表内容的信任和理解也可能影响对不确定性的认知。

因此，我们提出以下问题：(1)不确定性和过度自信偏倚是否会随着执业年限的增加而减少？(2)哪些社会人口学因素与对不确定性的认知较少独立相关，无神论与对不确定性的认识有何关联？(3)过度自信偏倚、对骨科循证的信任程度以及统计学的复杂程度是否与不确定性的认识独立相关？

材料和方法

研究设计

我们联系差异科学组(SOVG；上肢外科医生的国际合作组)的所有706名成员，以图完成关于不确定性认知的调查，其中7名成员选择退出SOVG(附录1[补充材料可从CORR的网络版获得])。SOVG是一个合作组，旨在研究在没有经济激励的情况下人类疾病定义和治疗的差异。剩下的699名成员主要为西方骨科医生(86%[599]在欧洲或北美执业)，他们参与教学(80%[560])。70%从事骨科创伤(33%[229])或手腕外科(37%[257])。经验分布相对平均，因为一半的成员执业10年以上 (47%[329])。加入后，SOVG成员同意接受问卷调查。参与我们的研究是自愿的；因此，我们没有获取额外的机构审查委员会的批准。调查邀请于2015年5月初发出，第2周和第4周时两次提醒。

调查问卷的制定

这项调查是由我们共同讨论了如何在日常临床骨科实践中处理不确定性后制定的。我们的目的是评估我们预测的与或多或少的不确定性相关的因素。选定的问题是我们从一个更大的群体中选择的更具相关性和挑衅性的问题。

随后，美国手外科研究协会Listserv(American Association For Hand Surgery Research Listserv)对这项调查进行了审查，美国手外科研究协会是一个手外科医师的合作组织，他们在研究方案的设计方面相互帮助，没有经济激励。确定基本信息要素之后，用四个问题以建立不确定性得分的总体认知。四个问题确定对骨科循证的信任水平，三个问题确定自信心偏倚的水平(相信自己的技能比实际水平更高)。在一个有序量表上选择答案；这样我们就可以将最终的特质分数标准化为0到10分来进行比较，0是每个特质可能的最低分，10是最高分。六道多项选择题衡量参与调查者的统计理解水平。这一特质也在0到10的量表上打分，0分表示没有正确答案，10分表示正确回答了所有六个问题。研究完成后，我们分析了项目在各自领域(收敛效度)和与其他领域(发散效度)的相关性。没有项目的发散效度高于收敛效度。这意味着每个项目主要测量自己的域，而不能更准确地捕获任何其他域。我们还测量了每个域的Cronbachα。这是内部一致性的度量；换句话说，一组项目作为一个组紧密相关的程度。如果项目关系更密切，则它们很可能度量的是相同的结构。

不确定性认知(0.70)和自信心偏倚(0.75)有相对较高的Cronbachα水平。对于统计理解（0.48）和骨科循证的信任度（0.37），α水平较低（表1）。调查结束时，还提出四个关于日常实践中不确定性的问题，其中最后一个开放问题问参与者，为什么他们的自信心会随着时间而改变。这些答案由两名调查人员(TT、SJ)归类。在独立分析主题并将主题分配给50项建议的子集后，通过讨论就这些类别达成共识。达成共识后，两位调查人员(TT、SJ)分析剩余的建议。在最后的分析中，我们将提高的诊断、手术和沟通技能归为经验，因为这些技能有望会随着实践而提高。类似于“我掌握的知识”这样的陈述归类为传闻结果。我们对类似于“获得更多知识”和“了解到知识缺乏”的说法进行了区分。每个参与者的回答可以分为三类。

研究群体

邮件送达706名组成员后，242人(34%)有回应。这不代表回复率，因为我们通过电子邮件发送的许多医生并不常参与调查，电子邮件地址也未进行确认。排除7名选择退出SOVG的成员后，我们发现剩余的应答者和无应答者(n=457)在性别、执业年限或专业方面没有差异。应答者更有可能是欧洲人(无应答者23%[457人中的107人]，应答者37%[242人中的90人]，p<0.001)，并带学生(无应答者76%[457人中的346人]，应答者88%[242人中的214人](附录2[补充材料可通过CORR在线版本获得])。

234人(97%)完成了调查；不完整的调查不做多变量分析。92%(222)为男性，51%(123)主要在医疗教学机构执业。大约一半(52%[126])在北美工作，其次是37%(90)在欧洲工作。60%(146)的人在政治上自由或适度自由，32%(76)的人保守或非常保守。60%(146)的人相信上帝，8%(20)的人没有意见，17%(40)是不可知论者，15%(36)是无神论者。只有8%(17)的人认为他们在毕业后教育培训结束后自信心有所下降(表2)。

统计分析

我们使用频率来描述离散变量；连续变量以均值和标准差(SDs)表示。为进行统计分析，我们将“你是否相信上帝和其他神？” 以及“你是否是一个信教的人？”的肯定和否定答案分开分组。

用费舍尔精确检验确定分类变量之间的差异。用非配对学生t检验和单因素方差分析确定连续变量和二分法变量之间的差异，对两个连续变量使用Pearson相关分析(表3)。解释性双变量分析中p<0.10的所有变量均输入多变量线性回归模型。我们认为双尾p值<0.05是显著的。

先验能力分析表明，185名参与者将提供0.80的能力来检测一个变量，该变量可以解释不确定性认知中3%的变异性，假设我们有五个预测因子的完整模型可以解释30%的变异性，α设置为0.05。

结果

日常实践中对不确定性的认知并不随执业年限而变化(0-5年，3.2±1.3；6-10年，2.9±1.3；11-20年，3.2±1.4；21-30年，3.3±1.6年；p=0.51)，但自信心偏倚随执业年限的增加而增加(0-5年，6.2±1.4；6-10年，7.1±1.3；11-20年，7.4±1.4；21-30岁，7.1±1.2；P<0.001)。关于毕业后教育培训后自信心如何变化的问题，大多数回答“减少”的人执业年限为21到30年 (0-5年，5%[83人中的4人]；6-10年，6%[53人中的3人]；11-20年，6%[73人中的4人]；21-30年，19%[33人中的6人]；p=0.038)(附录3[补充材料可在CORR.的网络版中找到])。在所有参与者中，大多数人表示，他们达到目前的自信心水平是因为增加了经验(58%[297人中的173人])和更多的知识(20%[297人中的58人])(图1)。当只评估自信心下降的21名参与者的陈述时，43%(9/21)将其归因于认识到骨科循证的局限性(图2)。

在考虑到混杂变量的潜在交互作用后，我们发现，与学院派执业相比，在多专业组工作与对不确定性的认知度较低(b回归系数，-0.53；95%可信区间[CI]，-1.0 to -0.055；偏R2，0.021；p=0.029)。

对上帝或任何其他神的信仰也与对不确定性的认知度减少呈弱相关(b，-0.57；95% CI，-1.0至-0.11；部分R2，0.026；p=0.015)。进一步分析显示，统计学理解，对上帝的信仰，与自认为是一个宗教人士相关联（多重共线性）。排除这些变量，我们发现，无神论者，与更大的不确定性认知呈独立的弱相关。(b，0.65；95% CI，0.2-1.11；部分R2，0.035；p=0.005)(附录4[补充材料可在CORR的在线版本中找到])。

自信心偏倚越大，对不确定性的认知度越低(b，-0.26；95%CI，-0.37 to -0.14；部分R2，0.084；p<0.001)。

对骨科循证的信任程度越高，对不确定性的认知度越低(b，-0.16；95% CI，-0.26至-0.058；部分R2，0.040；p=0.002)。

更好的统计学理解与更好的不确定性认知有更强的相关性(b, 0.25；95% CI，0.17-0.34；部分R2，0.13；p<0.001)。

我们的整个模型占不确定性认知可变性的29% (调整后的R2，0.29)(表4)。

讨论

缺乏证据似乎是日常实践的一部分，影响了大约50%的医学常见病[3]。医生对治疗的不确定性可能会对患者的健康产生不利影响。本研究的目的是评估骨科医生对不确定性的认知，并确定可能影响外科医生在日常骨科实践中如何看待不确定性的因素。在一个多专业组中工作时，对上帝或任何其他神的信仰，更大的自信心偏倚，以及对骨科循证的更大信任，与对不确定性的认知的减少呈弱相关。对统计数据的理解越多，对不确定性的认知就越强。

本研究存在一定的局限性。首先，SOVG的外科医生是骨科医生群体中的一个亚群。他们代表西方能够带教的学院派骨科医生。选用他们作为研究对象可能会导致选择偏倚，因为缺少非西方骨科医生或不参与教学的骨科医生。这限制了我们结果的普适性。其次，只有34%的SOVG成员填写了我们的调查。这本身并不是一个回复率，因为许多骨科医生并不常参与电子邮件调查，而且电子邮件地址也没有进行确认。此外，我们发现应答者和无应答者之间没有明显差异。第三，当我们衡量未经验证调查的可靠性时，我们发现每个调查项目都比其他任何一个项目更好地衡量了自己的特质。此外，对不确定性的认知和自信心偏倚具有相对较高的Cronbach alpha水平；换句话说，构成这两个特征的问题间有密切相关性，可度量相同的结构。然而对骨科循证的统计理解和信任较低。骨科文献中对不确定性的认知、对骨科循证的信任、自信心偏倚和统计学理解没有基准分数。对这些分数的解释是一个偏好和价值观的问题，直到有证据表明特定的观点或态度有益。

外科医生对不确定性的重视程度似乎不会随着经验的增加而改变。我们发现骨科医生普遍存在过度自信的倾向(认为自己的技能高于实际水平)，因为83%的人认为自己高于平均水平，没有人认为自己低于平均水平。同样，我们组中74%的人认为自己是高于平均水平的外科医生，25%的人认为自己是前5%的人。尽管这有可能是准确的--也许这组研究中的骨科医生高于平均水平--但这似乎更有可能归因于过度自信的偏倚。有证据表明，医学界的自信心和准确性是不一致的。例如，表现不佳的放射科医生对自己的诊断准确率很有信心[20]；一项对100名内科医生的调查发现，在非常困难和简单的临床病例之间，对于诊断准确性的自信心只有很小的差异，而实际的诊断准确率却有很大的差异[16]，而外科住院医师相信他们能在68%的时间里识别不同的桡骨远端骨折，而实际识别准确率只有33%[18]。过度自信偏倚可能会导致其他偏倚，比如可用性启发式(只考虑脑海中出现的第一件事)和确认性偏倚，即一个人只注意到与他或她的观点一致的事情，而不太注意支持另一种观点的事情[15]。限制医疗决策中的确认偏倚需要努力寻找不确定的证据，这是第二型(分析性、反思性、慢性型)，而不是第一型(快速、直觉、启发式)思维倾向的特征[7，25，26]。不能容忍不确定性的医生不太可能使用分析性思维，导致他们过度自信。

在学术机构工作的外科医生对不确定性的意识最强，特别是与那些在多专业组工作的外科医生相比。这可能与学院派医生更多地接触到教学、撰写论文和复杂的案例有关，因此在提供他们的建议的时候，更多的会提供循证证据，以支持自己的观点。在这种经常的知识检索中，他们可能会更加敏锐地意识到我们共享的知识库中的许多空白[3，17]。

我们研究中一个更有趣的发现是，我们发现有神论者(上帝或其他神的信徒)在日常骨科实践中对不确定性的认知较低。相反，作为一个无神论者，对不确定性的认知呈独立性正相关，能够对不确定性有更多的认知。有神论信仰对不确定性的影响与我们研究的其他影响一样强烈。虽然乍一看医生对上帝和宗教的个人观点似乎与如何看待医学证据无关，但我们的数据表明，两者之间可能存在某种联系。一个可能的解释是，极度有神论的欲望确定性，这种欲望通过他们的信仰实现，同样，对确定性的渴望可能会在医疗决策中延续到对确定性的渴望。有一些报告支持这样的观点，即不容忍不确定性是极度宗教化的人的一种品质[1，21，24]。通俗文学中也有大量关于有神论与确定性的解释[4，5]。此外，有人认为，信徒更有可能将不确定性视为知识的失败，而不是世界的内在事实[9]。在这些观点上，有神论对不确定性的否定，与真理只是近似的，所有的知识和理论都要根据额外的证据加以修正的观点相背。

自信心偏倚越大，不确定性越小。本研究组骨科医生表现出的自信心偏倚，这似乎与现有证据的匮乏不一致。外科医生处理争论和不确定领域的方式可能会影响他们对医疗决定和建议的合理性。一项研究描述了在最佳治疗证据有限的情况下影响手术决策建议的因素，发现“我能行”和“我知道咋治疗”等理由很普遍[12]。The Dartmouth Atlas[23]显示，与文献中有更多证据支持的手术相比，更多不确定性相关的手术率变化更大。内科医生，尤其是外科医生，由于需要满足患者的各种问题，而且许多患者感到自信会令人欣慰，他们自然难以面对不确定性。作为知情决策的一部分，患者可能更愿意，或许在伦理上应该意识到医学知识的边界。要做到这一点，医生需要意识到，并且应该能够简明扼要地向具有不同健康素养水平的患者阐明这些界限。平衡和客观的患者信息辅助工具，如决策辅助工具，可能有助于外科医生告知他们的患者。以前有作者报告，表达不确定性并不会降低患者的满意度[11]，而获得决策辅助的患者通常对他们的获得的诊疗更满意[22]。

对骨科循证的信任越大，不确定性就越小。对一些人来说，对骨科循证的信任可能会在医疗诊疗过程中发挥类似于日常生活中宗教的作用。已发表的研究可以作为一个锚，减少一些经历过的不确定性。然而，发表的文章中有很大一部分可能是不真实的[14]，即使是被高引用的研究也常常会随着时间的推移而遭到驳斥[13]。因此，对骨科证据抱有不可改变的信念是不必要的，而一种健康的怀疑主义似乎是一种更合适的态度，一些关于如何评判文献的杂志俱乐部可能会有助于实现这一点。

我们发现，那些在统计复杂度上得分较高的人对不确定性的认知程度更高。可以想象，更精通统计理解的受试者也更容易受到不确定性概念的影响。然而，即使在那些对不确定性认知更高的受试者中，统计理解的总体水平也较低，这一发现在其他研究中也很常见[2，6，27]。一些人认为，医生对卫生统计数据缺乏理解是影响医疗效率的主要障碍之一[10]。对不确定性的容忍度差异和对统计数据的理解不足可能会对诊疗产生可度量的影响。例如，那些对不确定性容忍度较低的人可能更倾向于采用更多的诊断检查，增加了成本，但也在不知不觉中引入了更多的假阳性和阴性结果。每次检查带来的额外不确定性可能会导致错误的决定。未来的研究可能会解决这种可能性。

我们的数据表明，在我们直接意识之外的内在和外在因素可能会影响外科医生如何看待不确定性。我们的目的是提醒大家注意这一点，并表明我们对外科医生日常生活中普遍存在的不确定性的认识存在差异。认识到我们对不确定性的容忍或不容忍会影响我们与患者沟通的方式。缺乏对不确定性的认知和过度自信可能会阻碍充分的知情同意和纳入患者的偏好。此外，对不确定性不能容忍的医生可能会采取更多的诊断性检查，从而提高成本并增加无益治疗的风险，这是一个值得进一步研究的课题。也许，改进住院医师的统计学教学、建立期刊俱乐部以提高对证据的评判和对偏倚的认知，以及在课程和会议上承认知识差距，可能会提高人们对现有不确定性的认知。

原文出处：

Clin Orthop Relat Res (2016) 474:1360–1369

原作者：

TeunTeunis MD, Stein Janssen MD, Thierry G. Guitton MD, PhD, David Ring MD, PhD,Robert Parisien MD

译者：

2016级临床医学系陈冬旭

审校:

西京医院骨科马真胜

英文原文：

DoOrthopaedic Surgeons Acknowledge Uncertainty?

Abstract

Background：Much of the decision-making in orthopaedics rests on uncertain evidence. Uncertainty is therefore part of our normal daily practice, and yet physician uncertainty regarding treatment could diminish patients’ health. It is not known if physician uncertainty is a function of the evidence alone or if other factors are involved. With added experience, uncertainty could be expected to diminish,but perhaps more influential are things like physician confidence, belief in the veracity of what is published, and even one’s religious beliefs. In addition, it is plausible that the kind of practice a physician works in can affect the experience of uncertainty. Practicing physicians may not be immediately aware of these effects on how uncertainty is experienced in their clinical decision making.

Questions/purposes：We asked: (1) Does uncertainty and over confidence bias decrease with years of practice? (2) What sociodemographic factors are independently associated with less recognition of uncertainty, in particular belief in God or other deity or deities, and how is atheism associated with recognition of uncertainty? (3) Do confidence bias (confidence that one’s skill is greater than it actually is), degree of trust in the orthopaedic evidence, and degree of statistical sophistication correlate independently with recognition of uncertainty?

Methods：We created a survey to establish an overall recognition of uncertainty score (four questions), trust in the orthopaedic evidence base (four questions), confidence bias (three questions), and statistical understanding (six questions). Seven hundred six members of the Science of Variation Group, a collaboration that aims to study variation in the definition and treatment of human illness, were approached to complete our survey. This group represents mainly orthopaedic surgeons specializing in trauma or hand and wrist surgery, practicing in Europe and North America, of whom the majority is involved in teaching. Approximately half of the group has more than 10 years of experience.Two hundred forty-two (34%) members completed the survey. We found no differences between responders and non-responders. Each survey item measured its own trait better than any of the other traits. Recognition of uncertainty (0.70) and confidence bias (0.75) had relatively high Cronbach alpha levels, meaning that the questions making up these traits are closely related andprobably measure the same construct. This was lower for statistical understanding (0.48) and trust in the orthopaedic evidence base (0.37).Subsequently, combining each trait’s individual questions, we calculated a 0 to10 score for each trait. The mean recognition of uncertainty score was 3.2 ± 1.4.

Results：Recognition of uncertainty in daily practice did not vary by years in practice (0–5 years, 3.2±1.3; 6–10years, 2.9±1.3; 11–20 years,3.2±1.4; 21–30 years, 3.3±1.6 years; p=0.51), but over confidence bias did correlate with years in practice (0–5 years, 6.2±1.4; 6–10 years, 7.1±1.3; 11–20 years, 7.4±1.4; 21–30 years, 7.1±1.2 years; p<0.001). Accounting for a potential interaction of variables using multivariable analysis, less recognition of uncertainty was independently but weakly associated with working in a multispecialty group compared with academic practice ( b regression coefficient, -0.53; 95% confidence interval [CI], -1.0 to -0.055; partial R2, 0.021; p=0.029), belief in God or any otherdeity/deities (b, -0.57; 95% CI, -1.0 to -0.11; partial R2, 0.026; p=0.015), greater confidence bias (b,-0.26; 95% CI, -0.37 to -0.14; partial R2, 0.084; p<0.001), and greater trust in the orthopaedic evidence base (b,-0.16; 95% CI, -0.26 to -0.058; partial R2, 0.040; p=0.002). Better statistical understanding was independently, and more strongly, associated with greater recognition of uncertainty (b,0.25; 95% CI, 0.17–0.34; partial R2,0.13; p<0.001).

Our full model accounted for 29% of the variability in recognition of uncertainty (adjusted R2, 0.29).

Conclusions The relatively low levels of uncertainty among orthopaedic surgeons and confidence bias seem inconsistent with the paucity of definitive evidence. If patients want to be informed of the areas of uncertainty and surgeon-to-surgeon variation relevant to their care, it seems possible that a low recognition of uncertainty and surgeon confidence bias might hinder adequately informing patients, informed decisions, and consent. Moreover, limited recognition of uncertainty is associated with modifiable factors such as confidence bias,trust in orthopaedic evidence base, and statistical understanding.

Perhaps improved statistical teaching in residency, journal clubs to improve the critique of evidence and awareness of bias, and acknowledgment of knowledge gaps at courses and conferences might create awareness about existing uncertainties.

Level of Evidence：Level 1, prognostic study.

Introduction

Much of the decision-making in orthopaedics rests on uncertain evidence. Well-designed randomized controlled trials frequently show no difference or a small and possibly unimportant differences between two treatments [8, 19].

Clinical Evidence [3] currently classifies 50% of 3000 common medical treatments as of “unknown effectiveness” and only 11% as proven beneficial (of the remainder 24% arelikely to be beneficial, 7% a tradeoff between benefits and harms, 5% unlikely to be beneficial, and 3% likely to be ineffective or harmful). Although a dearth of evidence seems part of everyday practice, physician uncertainty regarding treatment could diminish patients’ health, because many come to their provider for confident guidance. The degree to which providers perceive uncertainty about what is and is not actually known about matters relevant to everyday orthopaedic practice has not, to our knowledge, been measured.

As surgeons gain experience, it is plausible that what they previously considered to be uncertain becomes less so.

Recognition of uncertainty could be influenced by many other personal factors as well. There are some reports suggesting religion [1, 21, 24] and over confidence are important factors [7, 25, 26]. As evidence might replace uncertainty, confidence in, and understanding of, what is published might also influence the recognition of uncertainty.

We therefore asked: (1) Does uncertainty and over confidence bias decrease with years of practice? (2) What sociodemographic factors are independently associated with less recognition of uncertainty, in particular belief in God or other deity or deities, and how is atheism associated with recognition of uncertainty? (3) Do over confidence bias, degree of trust in the orthopaedic evidence, and degree of statistical sophistication correlate independently with recognition of uncertainty?

Materials and Methods

Study Design

We approached all 706 participants of the Science of Variation Group (SOVG; an international collaboration of upper extremity surgeons) to complete the survey on the recognition of uncertainty of whom seven participants opted out from the SOVG (Appendix 1 [Supplemental material is available with the online version of CORR.]). The SOVG is a collaboration that aims to study variation in the definition and treatment of human illness without financial incentives. The remaining 699 members represent mainly Western orthopaedic surgeons (86% [599] practice in Europe or North America), who are involved in teaching (80% [560]). Seventy percent specializes in orthopaedic traumatology (33% [229]) or hand and wrist surgery (37% [257]). Experience is relatively equally distributed, because half of the group has more than 10 years of experience (47% [329]). On joining, the SOVG participants gave approval to be approached for questionnaire studies. Participation in our study was optional; therefore, we did not acquire additional institutional review board approval. The first invitation was sent in the beginning of May 2015 and we sent reminders at 2 and 4 weeks.

Questionnaire Development

The survey was developed by us after a collaborative discussion about how uncertainty is treated in daily clinical orthopaedics. Our aim was to evaluate factors that we predicted would be associated with more or less uncertainty. The selected questions were the more relevant and provocative of a much larger group that we chose from.

The survey was then reviewed by the American Association for Hand Surgery Research Listserv, a collaboration of hand surgeons who help each other with the design of research protocols, without financial incentives. After baseline characteristics, four questions were used to establish an overall recognition of uncertainty score. Subsequently, four questions determined the level of trust in the orthopaedic evidence base and three questions determined the level of confidence bias (confidence that one’s skill is greater than it actually is). Answers were provided on an ordinal scales; this way we could normalize final trait scores to a 0 to 10 score for comparison with 0 being the lowest and 10 being the highest possible score for each trait. Six multiple-choice questions gauged the respondent’s level of statistical understanding. This trait was also scored on a 0 to 10 scale with 0 meaning no correct answers and 10 answering all six questions correctly. After completion of the study we analyzed item correlations in their domain (convergent validity) and with other domains (divergent validity). No items had higher divergent than convergent validity. This means each item measures predominantly its own domain and does not more accurately capture any of the other domains. We also measured the Cronbach alpha of each domain. This is a measure of internal consistency; in other words, how closely related a set of items are as a group. If items are more closely related, they probably measure the same construct.

Recognition of uncertainty (0.70) and confidence bias (0.75) had relatively high Cronbach alpha levels. The alpha levels were lower for statistical understanding (0.48) and trust in the orthopaedic evidence base (0.37) (Table 1). The survey was concluded by four additional questions regarding uncertainty in daily practice, of which the final open question asked participants why their confidence changed with time. These answers were categorized by two investigators (TT,SJ). Consensus on the categories was reached by discussion after independently analyzing and assigning themes to a subset of 50 suggestions. After this consensus, both investigators (TT, SJ) analyzed the remaining suggestions. In the final analysis we grouped improved diagnostic, surgical, and communication skills under experience because those are expected to improve with practice. Statements similar to “knowledge of what works in my hands” were categorized as anecdotal outcomes. We made a distinction between statements similar to ”acquiring more knowledge” and ”learned that there is an absence of knowledge.” Each participant’s answer could pertain to three categories.

Study Population

Of the 706 approached participants, 242 responded (34%). This does not represent a response rate per se, because many of the surgeons we email do not regularly participate, and the email addresses have not been confirmed. After excluding seven participants opting out from the SOVG, we found no difference in sex, practice years, or specialization between the remaining responders and nonresponders (n=457). Responders were more likely to be European (nonresponders 23% [107 of 457] versus responders 37% [90 of 242], p<0.001) and supervise trainees (nonresponders 76% [346 of 457] versus responders 88%[214 of 242] (Appendix 2 [Supplemental materials are available with the online version of CORR.]).

Two hundred thirty-four (97%) completed the survey; incomplete surveys were excluded from multivariable analysis. Ninety-two percent (222) were men, and 51% (123) worked predominantly in academic practice. Approximately half (52%[126]) worked in North America followed by 37% (90) working in Europe. Sixty percent (146) were politically liberal or moderately liberal, and 32% (76) were conservative or very conservative. Sixty percent (146) believed in God, 8% (20) had no opinion, 17% (40) were agnostic, and 15% (36) were atheists. Only 8%(17) thought their confidence had decreased since graduate training (Table 2).

Statistical Analysis

We used frequencies to describe discrete variables; continuous variables are reported as means and SDs. For statistical analysis we grouped separately the affirming and disaffirming answers to “do you believe in God, any otherdeity/deities?” and ”would you consider yourself a religious person?”

Fisher’s exact test was used to determine the differences between categorical variables. Unpaired Student’s t-test and one-way analysis of variance were used to determine the differences between continuous and dichotomous variables and Pearson correlations were used for two continuous variables (Table 3). All variables with p<0.10 on explanatory bivariate analysis were entered in a multivariable linear regression model. We regarded a two-tailed p value<0.05 to be significant.

A priori power analysis indicated that 185 participants would provide 0.80 power to detect a variable explaining 3% of the variability in recognition of uncertainty, assuming our full model with five predictors would explain 30% of the variability and alpha set at 0.05.

Results

Recognition of uncertainty in daily practice did not vary by years in practice (0–5 years, 3.2±1.3; 6–10 years, 2.9±1.3; 11–20 years,3.2±1.4; 21–30 years, 3.3±1.6 years; p=0.51) (Table 3); however, confidence bias did increase by years of practice (0–5 years, 6.2±1.4; 6–10 years, 7.1±1.3; 11–20 years, 7.4±1.4; 21–30 years, 7.1±1.2; p<0.001). To the question of how confidence changed after graduate training, the majority who answered ”decreased” were in the 21 to 30 years of practice group (0–5 years, 5% [four of 83]; 6–10 years, 6% [three of 53]; 11–20 years, 6% [four of 73]; 21–30 years, 19% [six of 33]; p=0.038)(Appendix 3 [Supplemental material is available with the online version of CORR.]). Of all participants, the majority stated that their current level of confidence was reached because of increased experience (58% [173 of 297]) and more knowledge (20% [58 of 297]) (Fig. 1). When assessing only the 21 statements of participants whose confidence had decreased, 43% (nine of 21) ascribed this to recognizing the limits of the orthopaedic evidence base (Fig.2).

After accounting for a potential interaction of confounding variables, we found that working in a multispecialty group, compared with academic practice, was weakly associated with less recognition of uncertainty (b regression coefficient, -0.53; 95% confidence interval [CI], -1.0 to -0.055; partial R2, 0.021; p=0.029).

Belief in God or any other deity or deities also was weakly associated with less recognition of uncertainty (b,-0.57; 95% CI, -1.0 to -0.11; partial R2, 0.026; p=0.015). Additional analysis showed statistical understanding, belief in God, and regarding oneself to be a religious person to be associated (multicollinear). On excluding those variables, we found that being an atheist was independently, weakly associated with greater recognition of uncertainty (b,0.65; 95% CI, 0.20–1.11; partial R2,0.035; p=0.005) (Appendix 4 [Supplemental material is available with the online version of CORR.]).

Greater confidence bias was some what correlated with less recognition of uncertainty (b,-0.26; 95% CI, -0.37 to -0.14; partial R2, 0.084; p<0.001).

Greater trust in the orthopaedic evidence base also was weakly correlated with less recognition of uncertainty (b,-0.16; 95% CI, -0.26 to -0.058; partial R2, 0.040; p=0.002).

Better statistical understanding was more strongly correlated with greater recognition of uncertainty (b, 0.25; 95% CI, 0.17–0.34; partial R2, 0.13; p<0.001).

Our full model accounted for 29% of the variability in recognition of uncertainty (adjusted R2, 0.29) (Table 4).

Discussion

A lack of evidence seems to be part of everyday practice, affecting approximately 50% of common conditions in medicine [3]. Physician uncertainty regarding treatment may adversely affect patients’ health. The aim of our study was to evaluate the acknowledgment of uncertainty by orthopaedic surgeons and to establish factors that might affect how surgeons regard uncertainty in daily orthopaedic practice. Working in a multispecialty group, belief in God or any other deity or deities, greater confidence bias, and greater trust in the orthopaedic evidence base were weakly associated with less recognition of uncertainty. Greater statistical understanding was more strongly associated with greater recognition of uncertainty.

This study has some limitations. First, surgeons of the SOVG are a subgroup in the community of orthopaedic surgeons. They represent Western orthopaedic surgeons of whom the majority supervises trainees. Using them as study subjects may have resulted in selection bias, because non-Western orthopaedic surgeons, or surgeons not involved in teaching, are not represented. This limits the generalizability of our results. Second, only 34% of the SOVG members filled out our survey. This is not a response rate per se, because many of the surgeons we email do not regularly participate, and the email addresses have not been confirmed. Also, we found no gross difference between responders and nonresponders. Third, when we gauged the reliability of our nonvalidated survey, we found that each survey item measured its own trait better than any of the other traits. Also recognition of uncertainty and confidence bias had relatively high Cronbach alpha levels; in other words, the questions making up these traits are closely related and probably measure the same construct.

However, this was lower for statistical understanding and trust in the orthopaedic evidence base.

There is no benchmark score for recognition of uncertainty, trust in the orthopaedic evidence base, confidence bias, and statistical understanding in the orthopaedic literature.

Interpretation of these scores is a matter of preferences and values until evidence suggests that specific opinions or attitudes are beneficial.

The degree to which surgeons regard uncertainty does not seem to change with greater experience. We found a pervasive overconfidence bias (confidence that one’s skill is greater than it actually is) among orthopaedic surgeons, because 83% of the group considered themselves to be above average diagnosticians, and none regarded themselves as below average. Similarly, 74% of our group regarded themselves as above average surgeons and 25% regarded themselves as being in the top 5%. Although it is possible that this is accurate—maybe the surgeons in this study group are above average—this seems more likely attributable to overconfidence bias. There is evidence that confidence and accuracy are at odds in medicine. For example, radiologists who performed less well were highly confident that they were accurate [20]; a survey of 100 internal medicine physicians found only a very small difference in confidence in diagnostic accuracy between very difficult and simple clinical cases, whereas there was a large difference in actual diagnostic accuracy [16], and surgical residents were confident they would recognize different distal radius fractures 68% of the time while actually identifying only 33% correctly [18]. Overconfidence bias can lead to other biases such as the availability heuristic (considering only the first thing that comes to mind) and confirmation bias, where a person notices only the things that agree with his or her point of view and is less attentive to support for alternative view points [15]. Limiting confirmation bias in medical decision-making requires an effort to seek disconfirming evidence, a characteristic of type 2 (analytical, reflective, slow) rather than type 1 (fast, intuitive, heuristic) thinking disposition [7, 25, 26]. Uncertainty-intolerant physicians might be less likely to use analytical thinking, contributing to their sense of over confidence.

Surgeons working in academic centers had the greatest awareness of uncertainty, especially compared with those working in multispecialty groups. This might be because academicians are more exposed to teaching, writing papers, and complex cases and as such might be more likely to be required to identify the foundations in evidence that underlie their propositions. In that search, they may develop a more acute awareness of the many gaps in our shared knowledge base [3, 17].

One of the more interesting findings in our study was that we found that theists (believers in God or another deity) showed less recognition of uncertainty in daily orthopaedic practice. Conversely, being an atheist was independently associated with greater recognition of uncertainty. The effect of theistic belief on uncertainty was as strong as the other effects we studied. Although at first glance a physician’s personal view on God and religion might seem to be irrelevant to how medical evidence is regarded, our data suggest that an association may exist. A plausible explanation could be that the highly theistic desire certainty and that desire is fulfilled with their belief and that same desire for certainty could carry over to a desire for certainty in medical decision-making. There are some reports supporting the contention that intolerance of uncertainty is a quality of people who are highly religious [1,21, 24]. There are also abundant explanations given in the popular literature relating theism to certainty [4, 5]. Furthermore, it is argued that believers are more likely to see uncertainty as a failure of knowledge rather than as an intrinsic fact of the world [9]. On these views, theism as a denial of uncertainty is in contradistinction to a view in which truth is only approximated and all knowledge and theories are subject to revision based on additional evidence.

Greater confidence bias was correlated with less uncertainty. Orthopaedic surgeons in this study group showed a confidence bias, which seems discordant with the paucity of available evidence. The way surgeons process areas of debate and uncertainty can affect their justification for medical decisions and recommendations. A study describing factors influencing recommendations for surgery in scenarios where evidence for a optimal treatment is limited found that justifications such as ”works in my hands” and ”familiarity with the treatment” are prevalent [12]. The Dartmouth Atlas [23] showed rates of procedures that are associated with more uncertainty vary more than procedures that have more evidential support in the literature. Physicians, and surgeons in particular may naturally have difficulty with uncertainty because of the need to satisfy patient questions and because many patients find confidence comforting. Patients likely would prefer and probably ethically should be aware of the boundaries of medicine’s knowledge as part of informed decision-making. For this to happen physicians need to be aware of and should be able to concisely articulate these boundaries to patients with various levels of health literacy. Balanced and dispassionate patient information tools such as decision aids might help surgeons inform their patients. Previous authors reported that expressing uncertainty does not diminish patient satisfaction [11], and patients provided with decision aids often are more satisfied with their care[22].

Greater trust in the orthopaedic evidence base was associated with less uncertainty. To some, trust in the orthopaedic evidence base may fulfill a role in health care similar to that of religion in everyday life. Published studies serve as an anchor to reduce some of the experienced uncertainty. However, a large part of what is published may not be true [14], and even highly cited studies often are refuted with time [13]. Having unwaivering faith in the orthopaedic evidence therefore is not warranted and a healthy skepticism seems a more appropriate attitude, something journal clubs on how to critique the literature might help to achieve.

We found greater recognition of uncertainty in those who scored higher on statistical sophistication. Conceivably, subjects who are more versed in statistical understanding also are more exposed to the concept of uncertainty. However, even among subjects who are more cognizant of uncertainty, the overall level of statistical understanding was low, a finding commonly noted in other studies[2, 6, 27]. Physicians’ lack of understanding of health statistics is thought by some to be one of the major impediments to health care efficiency [10]. Differences in tolerance for uncertainty and deficient understanding of statistics might have measurable effects on care. For example, those less tolerant of uncertainty may be more inclined to order more diagnostic tests, raising costs, but also unwittingly introducing more false-positive and negative results. The added uncertainty that each test brings might lead to erroneous decisions. Future research might address this possibility.

Our data suggest the possibility that intrinsic and extrinsic factors outside our immediate awareness may affect how surgeons regard uncertainty. Our aim is to draw attention to this and to show that there are variations in how aware we are of the prevalence of uncertainty in our daily lives as surgeons. Recognition of our tolerance or intolerance of uncertainty can influence how we communicate with our patients. A deficiency in recognizing uncertainty and apropensity toward over confidence might impede adequate informed consent and incorporation of patients’preferences. Furthermore, this intolerance of uncertainty could lead to ordering more diagnostic tests, thereby raising costs and increasing the risk of unhelpful treatments, a thesis that merits additional study. Perhaps improved statistical teaching in residency, journal clubs to improve the critique of evidence and awareness of bias, and acknowledgment of knowledge gaps at courses and conferences might create awareness about existing uncertainties.

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