General Medicine · Medical Literature
What aspects of clinical uncertainty are addressed by published competencies in evidence-based medicine? A scoping review
Abstract
Objectives Uncertainty is inherent within medicine. Evidence-based medicine (EBM) teaching within medical curricula seeks to prepare doctors to make clinical decisions within conditions of uncertainty. The goals and scope of training for medical students and doctors are defined by published EBM competencies. We conducted a scoping review to identify the aspects of clinical uncertainty that are addressed by EBM competencies. Design A scoping review was conducted to identify and synthesise existing literature and models of clinical uncertainty, with help from an advisory group. Reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Data sources Five databases (MEDLINE, EMBASE, PsycINFO, ERIC and Web of Science Core Collection) and supplementary searches. The searches were performed on 7 March, 2023, repeated and updated on 19 February 2025. Eligibility criteria for selecting studies We included empirical research studies that described uncertainty related to clinical decision-making in medical students and doctors. Data extraction and synthesis Screening against the inclusion/exclusion criteria, first using titles/abstracts and then full text, was conducted independently by EJ and one other author. Disagreements were discussed and resolved by the full team. Data from included studies were used to create an overarching framework and typology of clinical uncertainty relevant to EBM, which was then mapped to published EBM competencies. Results 44 of 3048 papers met the inclusion criteria. The overarching framework and typology described types of uncertainty, properties and modifiers of the uncertainty, which led to responses and strategies that clinicians adopted within conditions of uncertainty. The mapping process revealed that EBM competencies focus on the theoretical, technical and cognitive aspects of clinical uncertainty, and tend to neglect real-world clinical decision-making, doctor–p
Clinical relevance
Clinical uncertainty is an unavoidable feature of medical practice, yet the degree to which EBM training explicitly prepares doctors to navigate it remains poorly characterized. This scoping review addresses a critical curricular gap by systematically examining whether published EBM competency frameworks — which define training goals for medical students and practicing physicians — adequately cover the full spectrum of clinical uncertainty encountered in real-world decision-making. The findings are immediately relevant to medical educators, curriculum designers, and postgraduate training bodies seeking to align EBM instruction with the authentic cognitive and interpersonal challenges clinicians face.
Key findings
1. Of 3,048 papers screened across five databases (MEDLINE, EMBASE, PsycINFO, ERIC, Web of Science), 44 met inclusion criteria as empirical research describing uncertainty in clinical decision-making among medical students and doctors. 2. The authors developed an overarching framework and typology of clinical uncertainty comprising three interacting domains: types of uncertainty, properties and modifiers of uncertainty, and the responses/strategies clinicians adopt under uncertainty. 3. Mapping of this typology to published EBM competencies revealed that existing frameworks predominantly address the theoretical, technical, and cognitive dimensions of clinical uncertainty (e.g., evidence appraisal, probabilistic reasoning). 4. Real-world clinical decision-making dimensions of uncertainty — including contextual, relational, and systems-level factors — are systematically under-represented in published EBM competencies. 5. Doctor–patient interaction as a domain of uncertainty is notably neglected by current EBM competency frameworks, suggesting a structural gap between taught skills and the interpersonal realities of bedside decision-making. 6. NOTE: The abstract as provided was truncated; no specific quantitative effect sizes, confidence intervals, p-values, or NNT/NNH values were reported, consistent with the qualitative-synthesis methodology of a scoping review.
Practice implications
Medical educators and postgraduate training programme directors should audit their EBM curricula against this typology to identify and remediate gaps, particularly in real-world clinical reasoning, shared decision-making under uncertainty, and doctor–patient communication, rather than restricting instruction to critical appraisal and study design. Competency assessment tools should be expanded or redesigned to evaluate how trainees tolerate, communicate, and strategically manage uncertainty in authentic clinical encounters, not solely how they locate and appraise evidence in controlled settings. At an institutional level, specialty boards and licensing bodies should consider revising published EBM competency standards to explicitly incorporate affective, relational, and systems-level dimensions of uncertainty, ensuring that credentialing reflects the full complexity of modern clinical practice.