Postgraduate GPs’ experience of attending Medical Uncertainty Training during the Standardised Training of Residents: A qualitative process evaluation

doi:10.21203/rs.3.rs-4942750/v1

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Research Article

Postgraduate GPs’ experience of attending Medical Uncertainty Training during the Standardised Training of Residents: A qualitative process evaluation

https://doi.org/10.21203/rs.3.rs-4942750/v1

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Background

Uncertainty is a pervasive aspect of primary healthcare, significantly impacting clinical decision-making and patient outcomes. Medical Uncertainty Training (MUT) courses aim to equip healthcare providers with the skills needed to manage this uncertainty effectively.

Objective

To explore post-graduate General Practitioners' (GPs) experiences and perspectives on attending MUT courses during standardized residency training in China, focusing on the potential mechanism of such courses in handling uncertainty and identified areas for improvement.

Methods

A qualitative study utilizing semi-structured interviews was conducted with 15 post-graduate GPs, selected through purposive sampling from January 2024 to March 2024. Data were collected through in-depth interviews conducted face-to-face or via video conferencing, transcribed verbatim, and analyzed using NVivo14 software. Themes related to the course's structure, process, and outcomes were identified.

Results

Three principal themes emerged from the process evaluation interviews, categorized according to the Donabedian structure-process-outcome framework as teaching structure, teaching process, and teaching outcome. These themes were further subdivided into specific sub-themes including necessity of the course, comprehensive curriculum design, cognitive, emotional and behavioral education, flexibility and accessibility, interactive learning methods, continuous feedback and reflection, enhanced clinical judgment, increased resilience and confidence, Real-World application challenges.

Conclusion

The process evaluation findings provided more information on GPs' perceptions and experiences of attending MUT. Compared to increasing tolerance for uncertainty, medical students are more concerned with improving their personal competence in uncertain situations. By integrating cognitive, emotional, and behavioral education, the course builds GPs' confidence and skills in handling complex medical cases. Future research should validate these results across diverse settings and assess the long-term impact on clinical practice and professional development.

Medical Uncertainty Training

Process Evaluation

Postgraduate education

In primary healthcare, the dance with uncertainty is a constant theme defining clinical practice.¹ With each patient encounter, clinicians navigate numerous variables, ranging from the subtleties of symptom presentation to the complexities of diagnostic ambiguity.² In this intricate tapestry, uncertainty emerges as a formidable adversary, challenging healthcare professionals to tread the fine line between confident decision-making and prudent acknowledgment of the unknown.^3,4 Medical students who are not adequately prepared to handle uncertainty in the clinical environment may face cognitive dissonance, reduced self-efficacy, decreased empathy, maladaptive perfectionism, and ultimately, burnout later in their careers.⁵ Therefore, healthcare professionals must be equipped with the skills to navigate medical uncertainty.

Post-graduate General Practitioners (GPs) play a pivotal role in shaping the next generation of doctors by participating in the standardised training of residents in China.⁶ In response to the need to equip healthcare professionals with the skills to effectively navigate uncertainty, Medical Uncertainty Training (MUT) has emerged in residency training programs.⁷ Embedded in the standardised curriculum for residents, MUT courses foster the development of clinical acumen and resilience in the face of uncertainty. By incorporating medical uncertainty courses into standardised resident training, medical training institutions foster better understanding of how to approach ambiguous situations and make well-informed decisions.^8,9 However, the current curriculum on uncertainty lacks consistency. Research demonstrates significant links between physician and medical student uncertainty tolerance (UT) and healthcare-related outcomes. When UT is low, it is associated with negative outcomes such as increased healthcare resource use and more paternalistic patient care attitudes. Higher UT tends to protect against declining attitudes towards underserved patient populations.^10,11 Thus, most uncertainty courses focus on improving healthcare providers’ uncertainty tolerance, ¹²but few encourage critical thinking, evidence-based practice, and open communication among healthcare professionals.

We developed a curriculum that covers cognitive, emotional and behavioural interventions for students coping with uncertainty. Through lectures, case analysis, group discussions, role-playing, and practical exercises, participants gain a comprehensive understanding of the sources and dimensions of medical uncertainty; learn to recognise it in clinical practice; develop strategies to handle cognitive, emotional, and behavioural responses; and improve their communication skills with patients and colleagues, ultimately enhancing their ability and confidence to handle uncertain clinical scenarios (Appendix 1: Teaching plan of how to cope with uncertainty). In this study, we interviewed the GPs six months after they participated in MUT to explore their attitudes and perceptions towards conducting such medical uncertainty courses during resident training to clarify their significance in enhancing clinical competence.

2.1. Study Design and Participants

This qualitative study utilized semi-structured interviews to explore the experience and perception of attending MUT courses during the standardised training of residents. This research aimed not only to addresses the educational needs of future physicians but also has implications for patient safety, healthcare quality, and the professional development of medical practitioners. Based on these findings, the researchers can redesign and optimize a highly practical uncertainty course. Thus, we referenced the method of process evaluation in medical education, and set the main interview ideology to reflect students' motivation, training process and effect. The interview guide was developed based on the Donabedian structure-process-outcome framework and modified by two chief general practitioners included open-ended questions that allowed participants to elaborate on their thoughts.(Appendix2: Interview Guide for The Process Evaluation)

Participants were selected through purposive sampling to ensure a diverse representation of experiences and perspectives. Of the 27 post-graduate GPs who underwent the training invited to participate, 15 were ultimately included based on information needs and data saturation.

2.2. Procedure

The GPs were invited in-person to participate in the interviews directly after the course and telephonically six months later. They were all provided with an overview of the study's purpose and informed of the voluntary nature of participation. Upon obtaining their consent, individual interviews were scheduled at a mutually convenient time. The interviews were conducted in-person or via video conferencing platforms based on participant preference, and lasted approximately 25 minutes. During the interview, the interviewer did not evaluate the content of the conversation, but guided the topic and encouraged interviewees to express their views, feelings, and experiences. Each interview was audio-recorded with participants’ consent to ensure accurate data capture. Field notes were also taken to capture non-verbal cues and contextual information.

2.3. Data Collection and analysis

Semi-structured interviews were the primary data collection method. The collected audio recordings were transcribed verbatim and reviewed by the interviewer to ensure accuracy. The interview transcripts were anonymised and coded using NVivo14 qualitative analysis software. The process evaluation identified three primary themes: the necessity of the course, evaluation of content, and evaluation of practical application. These themes were further subdivided into subthemes. Initially, the coding process was independently conducted by the interviewers and their colleagues. Notably, only 1 new code emerged during the 13th interview. Subsequent interviews (14th and 15th interview), did not generate new codes, indicating data saturation. A line-by-line review of the coded text, with subthemes classified as topics, yielded new insights, which the primary research incorporated into the analysis.

2.4. Ethical Considerations

This study was part of the Graduate Education Reform and Curriculum Development Project (Project No. 040012023B064.) at Zhengzhou University and reviewed and approved by the Henan Provincial People’s Hospital, which is affiliated with the university. According to the guidelines, this research was classified as exempt from ethical review due to its use of anonymised secondary data that did not involve direct harmful interaction with human subjects. However, we explained voluntary participation, confidentiality, and potential risks and benefits to all participants. Informed consent was obtained from each participant before the study commenced. Participants were also reassured that choosing not to participate would not result in penalties or affect their grades, and that they could withdraw at any time without consequences.

3.1. Participants’ Sociodemographic Data

Among the residents who completed the MUT course, 15 ultimately participated in the process evaluation interviews. On average, the interviews lasted 15.20 minutes, ranging from 8–22 minutes. Table 1 shows the descriptive statistics of participants’ baseline sociodemographic data. Of the 15 participants, 9 (60%) were male. Their ages ranged from 24–30 years (mean 26 years, SD 0.57 years). Furthermore, 2 (13%) were unemployed social trainees, 4 (27%) professional master’s degree students, and 9 (60%) residents commissioned for training by other institutions. Six participants had 3–5 years of work experience, and the others were medical students who had just completed their undergraduate education.

Table 1. Sociodemographic data of the participants (N=15)

Variables		Commissioned trainees (n=9)	Master’s degree students (n=4)	Social trainees（n=2）
Gender n (%)	Male	3 (33.33)	1 (25)	2 (100)
Gender n (%)	Female	6 (66.67)	3 (75)	0 (0)
Age n (%)	＜25	1 (11.11)	3 (75)	1 (50)
Age n (%)	≥25	8 (88.89)	1 (25)	1 (50)
Education n (%)	Associate degree	2 (22.22)	0 (0)	1 (57.38)
	Bachelor degree	6 (66.67)	4 (100)	0 (57.38)
	Master degree	1 (11.11)	0 (0)	1 (50)
Length of service n (%)	＜3	5 (55.56)	4 (100)	1 (50)
Length of service n (%)	≥3	4 (44.44)	0 (0)	1 (50)
Marital status	Single	6 (66.67)	4 (100)	0 (0)
Marital status	Married	3 (35.59)	0 (0)	2 (100)
Personality Types n (%)	Extravert	4 (44.44)	2 (50)	0 (0)
Personality Types n (%)	Introvert	5 (55.56)	2 (50)	2 (100)

*The sources of trainees in our hospital are divided into three categories: the first consists of trainees commissioned by other medical institutions, the second includes postgraduate students, and the third comprises social trainees.

3.2. Qualitative Findings

The qualitative findings from the process evaluation of MUT courses are organised according to the Donabedian framework. We identified three primary themes: the structure of the course, teaching process, and practical application outcomes. These themes were further subdivided into subthemes (see Table 2) including the necessity of the course, comprehensive curriculum design, cognitive changes and behavioural transformation, flexibility and accessibility, interactive learning methods, continuous feedback and reflection, enhanced clinical judgment, increased resilience and confidence, and real-world application challenges.

3.2.1. Teaching structure

Theme 1: Necessity of the Course

Most participants highlighted the pervasive nature of uncertainty in clinical practice and the necessity of training to manage it. Understanding the importance of attending MUT increased residents’ motivation to participate therein. The most expressed view in this regard was that uncertainty in clinical practice can adversely affect the quality of patient care, leading to delayed or overly cautious decisions, resulting in suboptimal patient outcomes. MUT was essential in mitigating these impacts, as it enabled participants to better handle uncertain situations. It encouraged residents to discuss uncertainty with patients to foster trust and enhance doctor-patient relationships. Participants reported that the training increased their comfort in explaining uncertainties to patients, which improved patient trust and satisfaction. By involving patients in decision-making processes and managing uncertainty effectively, doctors can enhance patient satisfaction and adherence to treatment plans, ultimately improving overall patient care.

Besides the impact of uncertainty on patient care, participants noted that the lack of confidence in handling uncertain situations led to emotional distress and burnout. The training provided strategies for managing these emotions, helping to reduce stress and improve overall well-being. Residents reported feeling more confident and less anxious when facing uncertain clinical scenarios after completing the training. The structured approach to dealing with uncertainty boosted their decision-making confidence and encouraged positive behavioural changes such as active communication with patients and increased collaboration with colleagues. This improved clinical outcomes and reduced the sense of isolation in decision-making, contributing to a more supportive work environment.

Some residents expressed that they didn’t treat uncertainty as a challenge but an opportunity to improve their competence, since they realized that that one of the sources of uncertainty might be their own deficiencies, such as a lack of medical knowledge. This positive outlook had been instrumental in building their confidence and competence in handling ambiguous situations, ultimately leading to better patient care and professional satisfaction.

“...Before attending the course, I often felt hesitant and less confident when dealing with ambiguous diagnoses or treatment plans, which sometimes led to delays in patient management.(GP1)”

“...Uncertainty in medical practice used to take a significant toll on my mood and behaviour. I often experienced anxiety and self-doubt, which sometimes translated into defensive medicine practices, such as ordering unnecessary tests to cover all bases. (GP6)”

“...The MUT has been pivotal for my professional development. It has provided me with a framework to approach uncertainty not as a hindrance but as an integral part of medical practice. The skills and strategies I acquired through the course, such as reflective practice and evidence-based decision-making, have significantly enhanced my clinical competence.(GP2)”

Theme 2: Comprehensive Curriculum Design

Most participants considered curriculum design essential in equipping healthcare providers with the skills to manage uncertainty effectively, rather than merely increasing their uncertainty tolerance. The basic skills participants mentioned include recognising the nature of medical uncertainty, handling diagnostic ambiguity, decision-making under uncertainty, and communication strategies for discussing uncertainty with patients.

Students also reported that MUT balances theoretical knowledge and practical application. Lectures provided the necessary theoretical framework, while case analyses, group discussions, and role-playing exercises allowed participants to apply these concepts in real-world scenarios.

“...The MUT course thoroughly covered key topics essential for managing uncertainty in clinical practice. From understanding the sources and dimensions of medical uncertainty to learning about cognitive, and behavioural responses, the course content was comprehensive and well-structured.(GP2)”

“...The theoretical sessions provided a solid foundation, explaining the concepts and frameworks for understanding medical uncertainty. However, the practical exercises like role-playing, case analysis, and group discussions really enhanced my learning experience. I think we need a platform such as WeChat for post-course discussions.(GP11)”

Theme 3: Cognitive, Emotional, and Behavioral Changes and Transformations

The curriculum included cognitive and behavioural interventions. The cognitive interventions also taught critical thinking skills and strategies for recognising and addressing cognitive biases. The behaviour interventions focused on coping mechanisms for managing misconduct activities caused by stress and uncertainty, improving resilience, and fostering a positive attitude towards uncertainty using nudge theory. A subtheme regarding emotional changes when facing uncertainty emerged in the interviews, highlighting the interaction of cognitive, emotional, and behavioural aspects (Figure 1). Enhanced cognitive skills such as critical thinking and adaptability led to more effective and confident behaviours in clinical practice. Emotional resilience and stress management techniques enabled participants to maintain a positive attitude and stay composed, which influenced their behaviour. Positive behavioural transformation like increased collaboration and proactive decision-making reinforced cognitive development by providing practical experiences that enhanced critical thinking and adaptability, which replaced feeling anxious and overwhelmed with confidence.

“...The course highlighted the importance of recognising and accepting uncertainty as an inherent part of medical practice. This awareness helped me adopt a more measured and rational approach, reducing the likelihood of engaging in defensive or overly cautious medical practices that could harm patients or lead to resource wastage.(GP1)”

“...MUT provided strategies for maintaining professional integrity and making informed decisions without resorting to unnecessary interventions. This approach has made me more confident in my clinical judgments and less prone to doubt my decisions.(GP12)”

“...he training highlighted the emotional changes and interactions that occur when facing medical uncertainty. The course taught me techniques for emotional resilience and stress management, which have been invaluable in maintaining a positive attitude and staying composed in uncertain situations.(GP5)”

Figure 1: Relationships in Cognitive, Emotional, and Behavioural Education for Uncertainty Management

3.2.2. Teaching process

Theme 4: Flexibility and Accessibility

The MUT course was designed to accommodate the busy schedules of healthcare providers. For participants, the flexible scheduling options allowed them to attend sessions without disrupting their clinical responsibilities. However, many students noted that the course should be offered before entering the standardised residency training base.

“...The accessibility of this course was a significant advantage, as it allowed me to attend sessions without disrupting my clinical responsibilities.(GP4)”

“...I think the course should be offered before we enter the standardised residency training base. Having this training earlier would provide a strong foundation for managing medical uncertainty right from the start of our residency.(GP5)”

Theme 5: Continuous Feedback and Reflection

Most participants reported that MUT included regular and constructive feedback sessions with instructors and peers. These sessions provided insights into their performance, highlighted areas for improvement, and reinforced positive behaviours. Participants were encouraged to engage in self-reflection exercises, which involved analysing their experiences and identifying lessons learned. These exercises helped them internalise the training content and apply it to their clinical practice. The courses also fostered a collaborative environment where participants could give and receive feedback from their peers. This was valuable for gaining different perspectives and learning from others’ experiences. Many emphasised the importance of an iterative learning process, where participants could continually improve their skills through repeated practice, feedback, and reflection.

“...During the Medical Uncertainty Training (MUT) course, I regularly received constructive feedback from both instructors and peers. These sessions provided invaluable insights into my performance, highlighting areas for improvement and reinforcing positive behaviours.(GP4)”

“...By reflecting on my actions and decisions, I could better understand my strengths and areas where I needed improvement. This process of self-assessment was instrumental in helped me integrate the principles of uncertainty management into my daily practice.(GP8)”

3.2.3. Teaching Outcomes

Theme 6: Enhanced Clinical Judgment

Participants reported that MUT significantly improved their clinical judgment by enhancing their critical thinking and decision-making skills. They noted that this training enabled them to evaluate clinical situations more effectively and make better-informed decisions, leading to improved patient outcomes and overall quality of care. Many mentioned that the course improved their shared decision-making skills, allowing them to involve patients more in their treatment plans, which enhanced patient trust and satisfaction. They also highlighted that learning risk assessment skills helped them avoid medical negligence by making more balanced and informed decisions. Finally, they felt more confident in handling uncertainty, understanding it as an inherent part of clinical practice.

“...I particularly appreciated how the training improved my shared decision-making skills, allowing me to involve patients more in their treatment plans, which has greatly enhanced patient trust and satisfaction...Learning risk assessment skills also helped me avoid medical negligence by making more balanced and informed decisions.(GP5)

Theme 7: Increased Resilience and Confidence

Participants indicated that MUT significantly increased their resilience and confidence in handling uncertain clinical scenarios. The course provided evidence-based strategies for managing stress, which enhanced their stress management skills and supported their psychological well-being under pressure. Reportedly, the training taught them how to maintain composure during uncertain and stressful situations, which positively impacted their decision-making processes and overall clinical performance. Participants also felt empowered by the training, as it equipped them with the tools and confidence to approach challenges with a positive attitude and make informed clinical decisions.

“...One of the most valuable aspects of the MUT course was learning how to maintain composure in the face of uncertainty.By practicing these techniques, I’ve become more adept at handling difficult situations without letting stress or anxiety affect my performance.(GP3)”

“...This perspective shift has been incredibly liberating. I no longer see uncertainty as a personal failure but as an opportunity for growth and learning. The course equipped me with the tools to navigate uncertainty with confidence, which has empowered me to take a more proactive approach in my clinical practice.(GP14)”

Theme 8: Real-World Application Challenges

Despite the benefits, participants noted several challenges in applying the training in real-world scenarios. They noted varying levels of support from colleagues and the healthcare system, differences in patient populations, and complexity of integrating new skills into established routines as significant challenges. Adequate medical technical support including access to up-to-date medical information, diagnostic tools, and technical staff was often lacking. Furthermore, the variability in patient backgrounds, conditions, and preferences made it difficult to apply standardised approaches, necessitating tailored strategies that could be challenging to manage.

“...I faced several challenges when applying the training in real-world scenarios. One of the main issues was the varying levels of support from colleagues and the healthcare system.(GP10)”

4.1. Main Findings

This study explored post-graduate GPs’ experiences and perception regarding MUT. Reportedly, the training equipped participants with essential skills such as critical thinking, decision-making, and stress management. These skills enabled them to better evaluate clinical situations, involve patients in shared decision-making, and manage stress and uncertainty more effectively, improving patient outcomes and the quality of care. We conducted a process evaluation to explore the potential mechanism of such courses in handling uncertainty issues, identify areas for improvement, and determine three themes: course structure, process, and outcomes.

Unlike in other studies, our participants wanted to attend more courses in capacity enhancement rather than merely increase their uncertainty tolerance.¹³ The practical skills and strategies helped improve their clinical practice when facing uncertainty. Here, enhancing their ability to manage uncertainty with concrete tools and techniques led to better decision-making and patient care. This approach increased their confidence and competence in handling uncertain situations and increased positive patient outcomes and job satisfaction, and decreased stress and anxiety in their professional roles.¹⁴

Cognitive education in MUT plays a crucial role in enhancing healthcare providers’ abilities to recognise and mitigate cognitive biases, which significantly impact clinical judgment and decision-making.¹⁵ By focusing on bias recognition and providing strategies to counteract these biases such as confirmation bias and anchoring, the training enables providers to make more objective and balanced decisions.¹⁶ This systematic approach reduces the influence of personal biases, leading to more accurate diagnoses and effective treatment plans. Through reflective practice and structured decision-making frameworks, cognitive education fosters continuous learning and improvement, increasing providers' confidence in their clinical decisions and ultimately resulting in better patient outcomes and reduced medical errors. This emphasis on understanding and managing cognitive biases is essential for navigating the complexities and uncertainties of modern healthcare practice. ⁹Emotional education, an emerging theme in the MUT, enhances healthcare providers' ability to manage the psychological stressors of medical uncertainty through mechanisms like mindfulness, empathy training, cognitive-behavioural strategies, and reflective practice. These methods help providers maintain composure, recognise and modify negative thought patterns, improve communication skills, and learn from their clinical experiences.¹⁷ The impact of emotional education is significant, leading to enhanced resilience, decision-making, patient care, and positive behavioural changes. Providers become better equipped to handle stress, form stronger patient connections, collaborate effectively with colleagues, and maintain a healthier work-life balance, increasing job satisfaction and improving patient outcomes.¹⁸Integrating emotional education into medical training ensures that healthcare providers can navigate the emotional complexities of their profession more effectively. Thus, behavioural education in MUT enhances healthcare providers' ability to manage clinical uncertainty by promoting prudent decision-making, reducing over-treatment, and emphasising the importance of close follow-up.^19,20 Furthermore, by equipping providers with stress management techniques, it helps them remain calm and rational under pressure, leading to more thoughtful and deliberate decisions. Enhanced communication skills foster open dialogue with patients, allowing providers to explain uncertainties transparently and engage in shared decision-making. This collaborative approach reduces unnecessary interventions and aligns treatment plans with patient preferences, enhancing adherence to conservative treatments.

The design of the Medical Uncertainty Training (MUT) courses should prioritize flexibility and accessibility to accommodate the demanding schedules of healthcare providers. Incorporating diverse teaching methods such as lectures, case analysis, group discussions, role-playing, and practical exercises ensures comprehensive and engaging training. Continuous feedback and reflection are central, with regular feedback sessions and self-reflection exercises promoting deeper understanding and retention.²¹ This approach contrasts with traditional methods, which often lack the practical skills and continuous support needed for effectively managing uncertainty in clinical practice. By emphasizing iterative learning and real-world application, the MUT course enhances clinical skills, improves decision-making, and fosters resilience, ultimately contributing to better patient outcomes and higher quality of care.^22,23

4.2. Implications for medical education

The evaluation of the MUT course emphasized the need for comprehensive training which could equip healthcare providers to handle clinical uncertainty effectively.²⁴ Integrating uncertainty management into medical curricula is vital, as traditional education often neglects this aspect.By incorporating modules on critical thinking, decision-making, and stress management, one integrated curriculum contained cognitive, emotional and behavioral education is constructed which can better prepare students for real-world challenges. ²⁵ Continuous feedback and self-reflection are essential for fostering a growth mindset and lifelong learning, with regular feedback sessions guiding performance improvements. Flexibility in scheduling and accessible resources, such as online modules and recorded lectures, are necessary to accommodate busy medical professionals. Introducing the course early in medical training can maximize its impact. Addressing real-world application challenges requires robust support systems, including adequate technical support and up-to-date information access. Preparing students to adapt their approaches to diverse patient needs ensures high-quality care. Future research should focus on validating the MUT course’s effectiveness across diverse settings and its long-term impact, using larger sample sizes and extended follow-up periods. Integrating these findings into medical education will better prepare healthcare providers to deliver patient-centered care in a dynamic healthcare landscape.

4.3. Limitations

The study had several limitations that may impact the generalisability of the findings. First, given that the MUT course was part of a teaching reform project, participants’ age range was relatively concentrated, meaning most were likely at a similar career stage. This may have influenced the results, as the experiences and perceptions of a more diverse age group were not fully represented. Another limitation was the lack of a control group, making it difficult to attribute the observed improvements solely to MUT. Furthermore, the short duration of the follow-up period did not enable assessing the long-term impact of the training on participants' clinical practice. Last, this study was conducted at a single centre, which may limit the generalisability of the findings. Consequently, the applicability of the findings to other settings or institutions may be limited. Future research should consider multi-centre studies to validate and expand these results.

The MUT course is designed to emphasise cognitive, emotional, and behavioural education in facing uncertainty. Participants appreciated the comprehensive approach that helped them internalise the training and apply it in clinical practice. By focusing on enhancing abilities rather than merely increasing tolerance, the course fostered a deeper understanding and more effective management of medical uncertainty. Overall, MUT is essential in residency training, preparing GPs to confidently and competently handle uncertainties. Finally, designing such courses requires considering students’ preferences.

Ethics approval and consent to participate: This study was part of a teaching reform project at Zhengzhou University and reviewed and approved by the Henan Provincial People’s Hospital, which is affiliated with the university. According to the guidelines, this research was classified as exempt from ethical review due to its use of anonymized secondary data that did not involve direct harmful interaction with human subjects. Informed consent was obtained from each participant before the study commenced. Clinical trial number: not applicable.

Consent for publication: Not applicable.

Availability of data and material: The data generated and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests:All authors declare no competing interests.

Funding: This study was supported by the Graduate Education Reform and Curriculum Development Project of Zhengzhou University, Project No. 040012023B064.

Authors' contributions: Zhihui Liu and Liuyi Wang conceived and designed the study. Weili Shi and Yingshuai Zhao conducted the interviews and analyzed the data. Zhihui Liu drafted the manuscript, and all authors revised it critically for important intellectual content. All authors read and approved the final manuscript.

Acknowledgements: We would like to thank the participating residents who took time out of their busy clinical schedules to be interviewed and doctor Shuyi Wang for her contribution on the reviewing of this paper. This research was part of part of a teaching reform project at Zhengzhou University and funded by Zhengzhou University.

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No competing interests reported.

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Postgraduate GPs’ experience of attending Medical Uncertainty Training during the Standardised Training of Residents: A qualitative process evaluation

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