Becoming a practicing physician requires the completion of a residency program. In the final years of medical school students must choose which of the 30 direct entry specialties they wish to specialize in as a career, There are many factors which can influence a student’s choice in career paths: life style, location, and “fit”(1,2). The final years of medical school, also known as the clerkship years, are typically comprised of medical students getting first hand experience to various medical fields. This serves a two-fold purpose: to create a comprehensive foundation of medical knowledge, and to expose them to possible career choices.
Each specialty can vary in the degree of patient information available to practitioners. Patients can present with vague, non-specific symptoms, such as diffuse abdominal pain, or they can be precise such as fracture of the humerus due to a fall or anywhere in between that spectrum. Different presentations are associated with a different degree of ambiguity in: diagnosis, treatments, and outcomes. As such, different environments may potentially be better suited for certain personality traits. The purpose of this study is to investigate tolerance of ambiguity and perfectionism in medical students.
Tolerance of Ambiguity
Tolerance of ambiguity (TOA) refers to how we tolerate uncertain information. This has been defined as “the tendency to perceive ambiguous situations as desirable."(3) Interest in TOA in the medical field can be traced back to the early 1990s. Studies have often led to conflicting results, with some showing a larger, non statistically significant, TOA in 3rd year medical students (3) and other showing no different (4). Residents have been shown to have higher TOA compared to medical students (5). When looking at baseline data of 13867 matriculating first year medical students in the United states in 2013, higher TOA was seen in men and older individuals (6). Interestingly, there was a statistically significant relation between TOA and declared specialty of interest. Dermatology, Physical medicine and rehabilitation, otolaryngology having lowest mean TOA scores and Psychiatry, Radiation oncology, Emergency medicine, Neurosurgery scoring the highest TOA. However, this was an incidental finding and no further analyses were done. Other studies have shown that surgeons have a lower TOA than physicians(7).
Hancock, et al (2015)(5) developed a 29 item Likert scale specifically assess tolerance of ambiguity in clinical scenarios named: Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD). He demonstrated this scale showed good internal reliability and there was a difference between levels of training—with residents (foundational doctors) having higher tolerance of ambiguity than medical students. This was a cross-sectional study, which differs from our study looking at a longitudinal cohort study.
Perfectionism is a trait of interest in the medical field as it has been implicated in anxiety(8), depression(9), and burnout(10). While perfectionism may appear to have an intuitive definition, it is emerging to be a multi-dimensional construct. Recent research has identified three measurable dimensions of Perfectionism: rigid perfectionism, self-critical perfectionism, narcissistic perfectionism(11). Rigid perfectionism is defined as “flawless performance from the self”(12), self-critical perfectionism is defined as negative responses to flawed performances(13), and narcissistic perfectionism refers to expecting perfectionism from others(14). Medical students have been shown to have higher perfectionism scores than arts students, with maladaptive perfectionism being predictive of depression and academic distress(15), a result which has been replicated in other studies(10,16,17).
Feher, Smith, and Sakflofske (2019)(18) published the 16 item Big Three Perfectionism Scale–Short Form (BTPS-SF), which showed good test-retest reliability and good confirmatory fit from previously well validated 45-unit scale(14). We opted to use the short form for its ease of use and reliability.
This study was guided by three research questions:
- To what extent does a relationship exist between TOA and perfectionism for 3rd year medical students?
- How does clerkship modify these factors, and, or their relationship?
- Do these factors relate to student’s specialty choice?
The strength of this study comes from its multiple measurements of a single cohort. To date no studies have tracked a cohort over the course of medical training and looked at how TOA and perfectionism change as a function of exposure to clinical experiences.