Tolerance of uncertainty and reflection ability among medical students in Germany

Medical education researchers in Germany have taken one of the most detailed looks yet at how future doctors cope with two of the most psychologically demanding competencies in clinical practice: the ability to tolerate uncertainty and the capacity for structured self-reflection. In a new study published in BMC Medical Education, a team led by Christopher Holzmann-Littig and Nana Jedlicska, with Pascal O. Berberat and Marjo Wijnen-Meijer, surveyed first-year medical students at two of Germany’s largest universities, Ludwig Maximilian University of Munich and the Technical University of Munich. The results offer a technically nuanced and somewhat surprising picture of how tomorrow’s physicians think before their training even begins.

Uncertainty tolerance, often abbreviated as UT, refers to the degree to which a person can accept, process, and act constructively in situations where information is incomplete or outcomes are unpredictable. Reflection ability, or RA, describes the capacity to examine one’s own experiences, assumptions, and emotional responses in a deliberate and structured way. Both constructs have gained growing recognition as core competencies for healthcare professionals. Medicine is, by its nature, a discipline of incomplete data: diagnostic pictures rarely arrive fully formed, treatment responses vary from patient to patient, and evidence-based guidelines must often be adapted to individual circumstances. A physician who cannot function amid ambiguity may freeze, over-order tests, or default to rigid routines that do not serve the patient. Similarly, a clinician who cannot reflect on their own reactions may fail to learn from mistakes or recognize how their own biases shape clinical judgment.

Despite the acknowledged importance of these skills, the research landscape has remained fragmented. Prior studies on the associations between uncertainty tolerance, reflection ability, and individual characteristics such as age and gender have produced inconsistent findings, and relatively little is known about where medical students stand on these dimensions at the very start of their education. The German team addressed this gap directly by assessing UT and RA among students entering medical school, examining whether these traits correlate with age or gender, and exploring what the findings might mean for the tailored design of educational interventions.

The study took advantage of a compulsory joint course called Introduction to Clinical Medicine, which is shared by first-year medical students at both Munich universities. All first-year students were invited to participate in the survey during this course, giving the researchers access to a large and representative cohort at a standardized point in their training. The questionnaire was administered electronically via the EvaSys platform and included two validated psychometric instruments alongside demographic data. The first was the Groningen Reflection Ability Scale, or GRAS, a widely used measure of self-reflection capacity originally developed in the Netherlands. The second was the Uncertainty Tolerance Scale, or UTS, designed to capture multiple dimensions of how individuals respond to ambiguous or unpredictable situations.

A total of 761 participants were included in the final analysis, a substantial sample size that lends statistical weight to the findings. However, the researchers were careful to note the limits of their demographic data. Age could be determined for 384 participants, and gender for 493 participants, meaning that roughly half of the cohort provided complete demographic information for these specific analyses. The survey was anonymous and voluntary, and all participants gave written informed consent in accordance with the principles of the Declaration of Helsinki. The study was reviewed and approved by the Ethics Commission of the Technical University of Munich under approval number 433/19 S.

When it came to uncertainty tolerance, the results painted what the researchers described as a mixed picture. On one hand, students reported genuine openness toward novel experiences, suggesting a willingness to engage with unfamiliar situations and ideas. On the other hand, the same students simultaneously expressed a preference for predictability and routine, indicating discomfort with ambiguity and a desire for structured, familiar environments. This apparent contradiction is technically interesting because it suggests that uncertainty tolerance is not a single unified trait but rather a composite of partially independent dimensions. A student can be curious and adventurous in some respects while still craving certainty and control in others, and the UTS instrument appears sensitive enough to detect this internal tension.

To examine whether these traits varied with demographic characteristics, the researchers employed linear regression analysis, a statistical technique that models the relationship between a continuous outcome variable and one or more predictor variables. For uncertainty tolerance, the analysis revealed no significant association between overall UT scores and either age or gender, with all p-values exceeding the conventional threshold of 0.05. For reflection ability, the picture was similar: no significant association emerged between overall GRAS scores and age or gender, with the model explaining a negligible proportion of variance, R-squared equal to 0.002, and all p-values again above 0.05. In plain terms, knowing a student’s age or gender told you essentially nothing about their overall uncertainty tolerance or overall reflection capacity as measured by these instruments.

Yet the story did not end there. When the researchers drilled down to the level of individual questionnaire items, statistically significant gender differences did emerge, and these item-level findings are where the study becomes most provocative. Female students reported lower tolerance of uncertainty on specific items, suggesting that the gender gap in uncertainty tolerance may be concentrated in particular dimensions rather than distributed evenly across the construct. On the reflection side, female students reported a higher level of self-underestimation and self-doubt on specific GRAS items, indicating that while their overall reflection capacity was comparable to that of male students, the way they related to their own reflective process differed in emotionally significant ways. These patterns are exploratory, as the authors note, but they are consistent enough to warrant attention.

The technical distinction between overall construct scores and item-level responses is crucial for interpreting these findings correctly. Aggregate scores can mask meaningful variation at the subscale or item level, a phenomenon well known in psychometrics. Two groups can produce nearly identical total scores while differing substantially on individual items that pull in opposite directions. In this study, the absence of significant differences in overall UT and RA scores does not mean that gender is irrelevant to how students experience uncertainty and reflection. It means that the differences, where they exist, are localized in specific aspects of these multidimensional constructs. This is precisely the kind of nuance that can inform curriculum design: rather than treating all students as uniform, educators can target specific dimensions, such as building confidence in ambiguous clinical situations or addressing self-doubt in reflective practice.

The authors conclude that although overall uncertainty tolerance and reflection ability scores were not significantly associated with gender or age, the exploratory item-level analysis suggested gender-specific differences in certain aspects of both constructs. Given the high proportion of female students in the cohort, these differences may warrant further investigation and consideration in curriculum development to promote equitable opportunities and optimally prepare all students for clinical practice. The study is open access and carries the DOI 10.1186/s12909-026-10455-9, allowing educators and researchers worldwide to examine the full data and build on these findings. As medical education increasingly recognizes that psychological readiness is as important as scientific knowledge, studies like this one provide the empirical foundation for designing training that meets students where they actually are, not where aggregate statistics assume them to be.

Subject of Research: Tolerance of uncertainty and reflection ability among medical students in Germany

Article Title: Tolerance of uncertainty and reflection ability among medical students in Germany

Article References: Holzmann-Littig, C., Jedlicska, N., Berberat, P. O., & Wijnen-Meijer, M. (2026). Tolerance of uncertainty and reflection ability among medical students in Germany. BMC Medical Education, 26(1), Article 1517. https://doi.org/10.1186/s12909-026-10455-9

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10455-9

Keywords: Tolerance, uncertainty, reflection, ability, medical, students, Germany, scientific research