Qualitative study finds German general practice trainees lack dedicated training in managing clinical uncertainty

A qualitative study of 22 general practice trainees in Baden-Württemberg found that trainees experienced clinical uncertainty across personal, interpersonal and systemic dimensions, but reported little dedicated teaching on how to recognize, manage or communicate it. They used strategies including watchful waiting, seeking advice from colleagues, consulting external resources, making referrals and relying on clinical experience, while expressing a need for longitudinal training that begins earlier in their education.

The exploratory study was conducted from March to July 2025 among trainees in the Competence Centre Baden-Württemberg, a postgraduate general practice training program. Participants were recruited by purposive sampling from 651 trainees, with interviews conducted through Zoom. The sample included seven trainees entering general practice directly after medical school, eight who entered after postgraduate work in another field and seven who entered after completing another specialization. By the time of interview, participants had completed an average of 1.2 years of general practice training.

Researchers used a semi-structured interview guide developed by an interprofessional group with experience in qualitative research and primary care. The guide was assessed through think-aloud testing and pre-tested with two interviewees, leading to minor revisions. It addressed experiences of uncertainty, ways of managing and communicating it, previous education and trainees’ educational needs. The interviews were transcribed verbatim, and two researchers independently conducted qualitative content analysis, discussing and revising categories until agreement was reached. A third researcher was consulted if consensus could not be obtained.

The 22 interviews lasted a mean of 46 minutes, with a range of 36 to 70 minutes. The researchers reported that no new themes or codes emerged in the final interviews, indicating that meaning saturation had been reached. All participants were working in outpatient general practice. Because recruitment was purposive and the study was exploratory, the results were not intended to be exhaustive or statistically representative of all general practice trainees in Germany or elsewhere.

Trainees described intrapersonal uncertainty within themselves, interpersonal uncertainty arising through encounters with patients, trainers and colleagues, and systemic uncertainty arising from the healthcare setting. Intrapersonal uncertainty included perceived gaps in competence, fear of mistakes, insecurity and an obligation to disclose uncertainty. Interpersonal difficulties included unclear patient narratives, conflicting feedback and uncertainty about whether a patient might need specialist care. Systemic uncertainty reflected complex biomedical and psychosocial presentations, limits in guideline evidence and the inability to resolve every primary care problem immediately.

Participants reported greater perceived stress from uncertainty in outpatient care than in inpatient care. They associated this with patients presenting nonspecific symptoms or multimorbidity, limited access to rapid diagnostic tests and less frequent exchange with other disciplines. At the same time, many trainees regarded uncertainty as inherent and intellectually useful in general practice. Several described accepting the limits of their knowledge as contributing to humility, confidence and the development of their professional identity as general practitioners.

The trainees described a broad range of responses to uncertainty. These included collegial consultation, referrals, use of validated external sources, interprofessional networking, watchful waiting and communication with patients. As their experience in general practice increased, trainees said they became more willing to trust clinical intuition, although experience and intuition appeared to reinforce each other. They also emphasized the importance of a constructive error culture because it created a safe environment in which decisions and mistakes could be examined rather than concealed.

Although participants showed considerable interest in communicating uncertainty with patients, many feared that doing so could be interpreted as a lack of competence. They described observing and jointly reviewing a situation over time as one way to communicate uncertainty while keeping the patient involved. All participants referred to shared decision-making as the overarching approach, although the article notes that some patients accustomed to definitive answers may react with irritation to uncertainty that is shared openly.

Most trainees reported that uncertainty was addressed only incidentally during medical school and postgraduate training, creating a gap between formal education and the realities of everyday practice. They called for uncertainty management to be taught earlier, more openly and continuously. Suggested formats included supportive supervision, communication training, reflective seminars, peer and senior-colleague exchange, mentoring and opportunities to discuss apparently minor uncertainties. The researchers suggest curricula addressing intrapersonal, interpersonal and systemic uncertainty, supported by an error-friendly training environment.

The findings indicate an educational need rather than a tested intervention: the study did not evaluate whether uncertainty-focused training improves competence, mental burden, clinical outcomes or professional identity. Participants may have been more open-minded and empathetic than the average trainee, and the findings could be influenced by the German healthcare and training context. The authors therefore propose future mixed-methods, longitudinal research that measures uncertainty tolerance, professional identity formation and possible intervention effects.

Subject of Research: Perceptions, management strategies and educational needs associated with clinical uncertainty among German general practice trainees

Article Title: Facing uncertainty in primary care: perceptions, strategies and educational needs – a qualitative explorative study with German general practice trainees

Article References: Dreher, A. C., Scharli, P., Mitzkat, A., Becker, C., Altiner, A., & Schwill, S. (2026). Facing uncertainty in primary care: perceptions, strategies and educational needs – a qualitative explorative study with German general practice trainees. BMC Medical Education, 26(1), Article 1627. https://doi.org/10.1186/s12909-026-10550-x

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10550-x

Keywords: general practice, clinical uncertainty, medical education, postgraduate training, trainees, qualitative study, watchful waiting, shared decision-making, professional identity, Germany, Facing, uncertainty