Reply Physician Tolerance of Uncertainty

The study reporting an association of physician low “tolerance of uncertainty” with physician burnout¹ errs by framing physician burnout as a physician “coping problem” rather than a healthcare system problem. The authors assert, “Physicians need to learn to work amidst a plethora of uncertainties, which may drive burnout”; “tolerance of uncertainty” is … “ a state” … “amenable to change” [with] “influence from inherited personality traits and prior environmental influences”; and “understanding and acknowledging uncertainty and acquiring proper coping strategies is … a core clinical competency.” The exhaustive National Academy of Sciences report in October 2019 instead addressed clinician burnout with a systems approach, noting, “Mounting pressures have contributed to a situation in which the demands of the clinician’s job are greater than the resources available to complete the job effectively.”² Moral injury is the adverse outcome of barriers encountered to patient care, where the clinician knows what care the patient needs but is unable to provide it, due to constraints beyond the clinician’s control.³ Moral injury, then, leads to health system-related burnout that provider-focused interventions will not mitigate. Like patient safety, burnout is better understood as a failure of “the system” rather than individual providers.⁴ Clinician burnout is indeed associated with low-quality care⁵. The solutions, however, lie in changing the system to better equip the clinician to deal with system dysfunction and moral injury, rather than blaming the clinician for lack of “tolerance of uncertainty.”