Tolerating ambiguity as a Foundation doctor

In our study we are looking at the work doctors do, and using a range of measures related to wellbeing, including stress and burnout. In this post Dr Jason Hancock (Consultant Liaison Psychiatrist, Devon Partnership Trust & Honorary Clinical Lecturer, University of Exeter Medical School) writes about another of our key measures which may play an important role in wellbeing.


As part of this study we are collecting data on how interim F1 doctors respond to ambiguity in clinical practice. Both ambiguity and uncertainty are inherent within the practice of medicine. I recall when I was a foundation doctor even seemingly simple tasks, such as prescribing Warfarin, would be associated with significant uncertainty. For example it was often unclear what the patient’s usual Warfarin prescription was, why they were taking Warfarin, what their target INR should be, how much Warfarin they had actually been taking before admission, and if any changes to other medications since admission would be impacting on the metabolism of Warfarin. While some of the challenges associated with the prescription of Warfarin may have now reduced with the rise of new anticoagulant medications, the issue of managing and tolerating uncertainty remains. 

One of the challenges with research into this field to date has been the interchangeable use of the terms ambiguity and uncertainty. When we refer to ambiguity we mean a clinical situation where there is imprecise, missing, or conflicting information. When we refer to uncertainty we mean a clinical situation where we are consciously aware that we do not know what the outcome will be. This can be caused by many things including ambiguity or complexity. 

As a psychiatrist I am particularly interested in how our ability as doctors to tolerate ambiguity or uncertainty may be linked to our own psychological well-being, and his has been the focus of my research to date. 

To help evaluate how tolerant of ambiguity medical students and junior doctors are within clinical practice we developed the TAMSAD (Tolerance of Ambiguity in Medical Students and Doctors) scale. This scale was initially developed and validated in a population of medical students and foundation doctors in Exeter, and has since been used in a wide range of populations including veterinary students. 

Through taking part in this research and completing the TAMSAD, alongside other measures, you will help us understand how an ability to tolerate ambiguity may be linked to your own psychological well-being as doctors. It will also provide us with valuable information about the how doctors working in rapidly developed and novel roles such as yours tolerate ambiguity, and how practising within the context of a global pandemic can impact on your own ability to tolerate ambiguity and uncertainty in clinical practice.

Through better understanding these potential associations we hope to be better placed to develop educational interventions to help newly qualified doctors, such as you, tolerate and practice within an ambiguous and uncertainty clinical world. 

Phase 2: the work and wellbeing of new F1s

As FiY1 posts come to an end, so too does Phase 1 of our project. We have some great data on the work activity and wellbeing of doctors in those posts. Our sincere thanks to those who have taken the time to complete questionnaires.

At the moment we have responses from about 10% of FiY1s, although with some regions better represented than others. FiY1s who have completed their posts in the last three weeks will have a final opportunity to add to this dataset at the end of FiY1 before we move on to Phase 2.

Foundation SchoolQuestionnaire
East Anglia5
Essex, Bedfordshire & Hertfordshire9
Leicester, Northamptonshire & Rutland11
North Central and East London 19
North West London9
North West24
S Thames34
W Midlands21
Yorkshire & Humber60
Northern Ireland39
 Total (inc Foundation School not known)460

Phase 2 – welcome to new F1s

So far we have been concerned with the work and wellbeing of those in FiY1 posts. In Phase 2, the scope broadens to encompass all doctors starting F1. We will be collecting data in August – within the first two weeks of starting F1 after shadowing – and in September, when F1s will have become more accustomed to their new roles.

These questionnaires will be similar to that completed during FiY1, but with an additional focus on how prepared for different aspects of work new doctors feel.

All new F1s should get a reminder about the study during their F1 induction. If you have already signed up to take part in the study you will receive a questionnaire link at the email you signed up with. If not (or if you are unsure) you can still sign up at

A researcher’s view: the importance of understanding wellbeing

In this post, Professor Karen Mattick from the University of Exeter gives a personal view on the importance of this study.

My interest in the study is three-fold: firstly, the opportunity to research something as important and timely as Covid-19; secondly, to extend our existing Exeter-based research on wellbeing and tolerance of ambiguity; and thirdly, the chance to collaborate with a national consortium of highly-regarded medical education researchers doing impactful work supported by the UK professional regulator.

The importance of the study is vital. Given the monumental changes to healthcare driven by Covid-19, it is vital that we evaluate the impact on healthcare professionals, both their WORK and their WELLBEING.  This project provides an opportunity to focus on one of most affected groups: new doctors graduating in 2020.

The opening sentence of a New England Journal of Medicine article by Pfefferbaum & North in April 2020 reads “Uncertain prognoses, looming severe shortages of resources for testing and treatment and for protecting responders and health care providers from infection, imposition of unfamiliar public health measures that infringe on personal freedoms, large and growing financial losses, and conflicting messages from authorities are among the major stressors that undoubtedly will contribute to widespread emotional distress and increased risk for psychiatric illness associated with Covid-19”.  Our project provides an opportunity to focus on a group which may be one of the most affected by all this uncertainty: new doctors graduating in 2020.  

Early data analysis is already providing intriguing insights into the experiences of new medical graduates during Covid and we look forward to sharing those in coming months.

The view from FiY1: adjusting to work

There has been lots of interest in the experience of doctors in FiY1 posts over the last few months. Dr Molly Dineen has been working as FiY1 in Truro. Here she shares some of her experiences.


At the end of February I was travelling to New York for my medical elective, excited for the two months which I was about to spend in the USA and South Africa. Two weeks later I was on my way home, as COVID-19 began to spread across the globe and just a few weeks after that, I was starting work as a junior doctor in the NHS.

The decision to graduate early and start work, three months earlier than expected, was not an easy one. I was aware I would be entering the NHS at a challenging time, but ultimately I wanted to do my bit to help, and to relieve pressure on the more senior doctors who were already working so hard.

I was lucky to have had lots of clinical experience throughout my medical degree at Exeter and having completed our final exams at the end of our fourth year, the last year was focused on gaining experience in practice. This clinical experience meant I felt ready to take on the role of an interim Foundation Year 1 doctor. I felt privileged to be in a position where I could use the skills gained over the last five years to help.

I started working at the Royal Cornwall Hospitals Trust (RCHT) on the Acute Medical Unit, seeing all medical admissions, of all ages and conditions. Starting work as a junior doctor in the middle of a worldwide pandemic was quite frankly terrifying, but the experience turned out to be enjoyable and rewarding.

The biggest challenges that I experienced were adapting the skills learned during medical school to the new environment where we were social distancing and wearing personal protective equipment. Whilst our number of covid-19 cases remained low, we still worked to prevent further spread. I had to communicate with patients through a mask, using only my eyes to express my thoughts and only my patient’s eyes to understand their emotions. I had to re-learn to conduct basic examinations at a safe distance with protective clothing on, and to take a full history from a patient without paper notes, to reduce contamination. 

I had to adapt to this new environment in a matter of hours as I also adjusted to being a new doctor. I had to attempt to ignore all that was going on around me as I faced the challenging questions: “Do you think its cancer?”, “Is she going to die?”. It had been easy to forget that in many ways life continued despite the restrictions, and returning to the hospital was a clear reminder of that. 

The whole team I worked with – nurses, doctors, physiotherapists, occupational therapists, ward clerks, porters, cleaners, physician associates and emergency medical technician – remained positive and upbeat despite the challenges. There was a great sense of team spirit and I have felt so lucky to be welcomed into this team of people who have been working so hard for many months through the Covid-19 pandemic. 

As lockdown rules continue to ease, there will be many more people heading back to work, adapting their own environments and putting themselves at risk in order to help us all move back to normality. I hope that we all continue to work as one big team to reduce the spread of Covid-19 and that we respect the challenges that everyone faces. My new understanding of the challenges, even in an area which has been less affected than some, has emphasised the importance of this to me.  The fewer the cases, the fewer restrictions we will have on access to healthcare and the more normal life can become again.


Blog adapted from articles here and here. Many thanks to Molly for allowing us to reproduce her words.

Molly has also kept a video diary which was featured on BBC News:

Don’t forget, participants in this project can contribute their own stories to our analysis through the free text link included in the questionnaire email.

Questionnaire update

We have had a great response to the questionnaire from across the UK, with around 15% of all FiY1 doctors having completed our questionnaire (this is a very good figure for this sort of online questionnaire).

In order to collect longitudinal data, questionnaires have been distributed on a three-week rolling schedule. Many people have now received two links, and some this week have received a third. We know that many people have come to the end of their FiY1 posts as F1 induction approaches at the end of the month, and so this will mark the end of data collection Phase 1. If you get a questionnaire link and have finished your FiY1 post, please do follow the link – there are options to record that.

Phase 2, where new doctors starting F1 directly will also be included, will begin during F1 induction, and we are working with colleagues at Foundation Schools to make sure everyone is aware of the project.

We will give a round up of Phase 1 on the blog next week.

A researcher’s view: the start of the project

In coming weeks we will be including some more personal views of the project from members of the research team, and some of our FiY1 partners. In this post Bryan Burford describes the genesis of the project.


As the pace of the covid-19 pandemic changed rapidly in the first weeks of March, I remember thinking what a strange time it must be to be a medical student approaching graduation, unsure of how it may shape the already uncertain period of transition to clinical practice.

When I became aware of the FiY1 initiative, early in lockdown, I was struck by what this would mean for graduates. The acceleration from thinking that there are a few months of medical school remaining, to potentially starting work in a few weeks, with no final exams, must be very unsettling, to say the least!

On the other hand, knowing many medical students and how keen final years are to enter practice and apply all they have learned, I thought that many must be feeling excited at the prospect of having a period of work before starting Foundation Programme. 

Conversely, those who do not take on an FiY1 post – either through choice, or because they did not graduate early – must also be having mixed feelings.

These thoughts resonated with much of the work Gill Vance and I have been doing over the last few years around transitions through medical school and beyond – questions of ‘preparedness’ and personal adjustments to practice, and challenges to the wellbeing of medical students and doctors.

We quickly drafted an outline proposal and having already started building relationships with other medical education researchers across the UK as part of the development of the NIHR Incubator in Clinical Education, were soon able to pull together a team and a plan. The GMC agreed to fund the project, and by May we were finalising the questionnaire materials you have seen and approaching other stakeholders to support data collection.

While the rapid development of projects is not new to us, the pace of this felt new – in part because the world was changing to rapidly around us, and so any data we collect would be far more time-critical than in ‘normal’ times (hence the longitudinal design). There’s also an awareness that this is a historic moment, and we have a unique opportunity to hear from the ‘class of covid’ (a phrase I came across on Twitter, used by newly graduating medical students). 

We also have to consider that this may not be the last pandemic – and indeed that the current one is by no means over. Understanding the experience of starting work in such unusual circumstances now – whether as FiY1 or as F1 in August – will help ensure that any future changes are informed by the best evidence.

Learning from this unusual set of circumstances may also guide approaches to best address the longstanding challenges of the transition to professional practice in the ‘new normality’.  

About the team

With the project well underway, it’s a good time to introduce the team undertaking the project. We will have posts from individual team members in coming weeks, but this post will be a quick introduction to us all.

The project is being led from Newcastle University School of Medical Education by Dr Bryan Burford, and Dr Gill Vance. Bryan has a background in social and cognitive psychology, while Gill is a clinician as well as a researcher in medical education. Gill works as a consultant in paediatric allergy at Newcastle’s Great North Children’s Hospital. She is also the Director for the Academic Foundation Programme in Northern Foundation School. Since 2013, Bryan and Gill have completed several projects looking at the work, preparedness and wellbeing of medical students and junior doctors, much of this for the GMC. They are also behind the newly announced NIHR Incubator for Clinical Education. This project represents the first collaboration since the Incubator was confirmed.

At The University of ExeterProfessor Karen Mattick has a particular interest in the links between education, research and practice. She has also completed work for the GMC looking at preparedness, and is a co-lead of the Centre for Research in Professional Learning at Exeter. Karen developed the Care Under Pressure project for the NIHR, which aimed to understand factors shaping doctors’ mental health and to co-produce recommendations that support the tailoring, implementation, monitoring and evaluation of contextually-sensitive strategies to address mental ill-health in doctors. The project was led by Dr Daniele Carrieri, and Karen and Daniele are developing a follow up to that work. 

At Plymouth University, Professor Tom Gale combines educational and clinical expertise as a consultant anaesthetist and Professor of Medical Education at the Peninsula Medical School.  Dr Nicola Brennan is a social scientist by background, and has been working in medical education research for 13 years. Tom and Nicola lead the education research group, CAMERA, which carries out research focused on the development, recruitment and retention of a sustainable healthcare workforce. They will shortly be launching a study commissioned by the GMC to investigate specific themes underpinning  new doctors’ preparedness for practice.

At Queens University Belfast, Professor Tim Dornan has a particular interest in understanding clinical workplace learning. His work has involved many aspects of practice, including doctors’ empathy and readiness for prescribing. A recent publication also looked at another doctors’ adaptation in another natural disaster – the Japanese earthquake and tsunami of 2011. Tim is also a (now retired) physician and endocrinologist.

The team brings together a range of clinical and non-clinical backgrounds, expertise with quantitative and qualitative methods, and interests in all areas of new doctors’ work and wellbeing. Our driving focus is to ensure that the project allows us to understand the experience of doctors starting work in this challenging period so that they, and stakeholder organisations across the UK, can identify challenges – and positive experiences – to learn for future policy and practice.