Situating “uncertainty” in communities of practice and competency-based medical education

This blog post discusses Jordan & McDaniel’s (in press) conceptualization of “uncertainty,” and seeks to situate that “uncertainty” in Wenger’s (2000) visualization of organizational structure.  We will also apply these theories to the adoption of competency-based assessments in graduate medical education.

Jordan and McDaniel describe uncertainty as

“an individual’s subjective experience of doubting, being unsure, or wondering about how the future will unfold, what the present means, or how to interpret the past” (pp. 3).

For them, this concept is central to the process of learning.  However, they also note that uncertainty may play differing roles in learning outcomes.  Uncertainty can as easily be considered a desirable outcome—for example, in demonstrating the complexity of a concept, or the limits of a learner’s knowledge on a subject—as an undesirable one—where learners respond to an “impulse” to reduce their uncertainty (pp. 4).

Wenger, speaking systemically of our communities of practice, outlines two major types of knowledge: social competence, meaning the socially and historically situated understanding of our community; and experience, which captures personally acquired knowledge that may or may not align with wider societal beliefs (pp. 226-227).  When social competence and experience clash, this creates space for learning to occur, and knowledge, be it societal or individual, to change (pp. 227).

How, then, does uncertainty fit in Wenger’s community of practice?  Jordan & McDaniel have outlined two potential theories: Uncertainty can take the place of individual experience.  As Jordan & McDaniel note, uncertainty (particularly in a classroom setting) can be very experiential; it is a common modality for learners to see and challenge the structure of their classroom, or relationships with fellow students.  Uncertainty, however, can also take the place of learning, or as a part of learning, that allows learners to identify questions regarding societal competence and to be inquisitive about their social knowledge.

The below example, discussing core curricular expectations of graduate medical education, is an example of uncertainty as both a mode of experience as well as a situation for learning.  

The American Council for Graduate Medical Education (ACGME) is the nonprofit accrediting body for American medical schools; it focuses upon “graduate” medical education, meaning residency programs, internships, fellowships and the like, rather than “undergraduate” medical institutions, which award the MD or DO degrees.  Traditionally, “variability in the quality of resident education” was a major systemic stressor (Nasca et al. 2012, pp. 1051).  In response to this, the ACGME historically focused upon quality of teaching and program structure when evaluating an institution.  However, to many such institutions, this focus created an undue administrative burden, stifling innovation, reducing staff and faculty availability to mentor students, and lagging behind systemic changes in the wider medical system.  In 1999, the ACGME introduced six core competencies that, in order to remain accredited, graduate medical education programs must include in their curriculum (Nasca 2012):

  • Medical Knowledge (MK)
  • Patient Care (PC)
  • Interpersonal Skills and Communication (IPC)
  • Professionalism (P)
  • Systems-Based Practice (SBP)
  • Practice-Based Learning and Improvement (PBLI)

The six factors outlined above were designed to shift administrative focus toward tangible “outcomes and learner-centered approaches” (pp. 1052).  For learners, it shifted the focus of medical curriculum closer to real world application.  With traditional didactic lecturing concentrated within one of the six categories, this system presented a unique opportunity to reduce the uncertainty that existed between rote medical knowledge and the myriad of other competencies expected of a practicing physician.  It mandated space within the medical curriculum to both experience parts of being a physician beyond a textbook knowledge of medicine or medical procedures—displaying professionalism with patients, families and other medical professionals; clearly communicating complicated concepts to lay audiences; refine their bedside manner, and practice composure in emotionally difficult situations.  The addition of “System-Based Practice” and “Practice-Based Learning and Improvement” also gave learners the room to confront uncertainty as a part of Wegner’s learning: To practice critical reflexivity, identify strengths and weaknesses in the current structure of the medical system, and to situate themselves as physicians and advocates within that system.



Jordan, M.E. and McDaniel, R.R. (In Press). “Managing uncertainty during collaborative problem solving in elementary school teams: The role of peer influences in robotics engineering activity.” The Journal of the Learning Sciences, 1-49.

Nasca, TJ et al. (2012). “The next GME accreditation system: Rationale and benefits.” New England Journal of Medicine, 366(11), 1051-1056.

Wenger, E. (2000).  “Communities of practice and social learning systems.” Organization, 7, 225-246.

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