Social Science & Medicine 56 (2003) 603–616 A certain art of uncertainty: case presentation and the development of professional identity L. Lingard a, *, K. Garwood a , C.F. Schryer b , M.M. Spafford c a Department of Paediatrics, Faculty of Medicine Centre for Research in Education at the University Health Network, University of Toronto, 200 Elizabeth Street, Eaton South 1-604, Toronto, Ont., Canada M5G 2C4 b Department of English, University of Waterloo, 200 University Avenue West, Waterloo, Ont., Canada N2L 3G1 c School of Optometry, University of Waterloo, Waterloo, Ont., Canada N2L 3G1 Abstract Healthcare professionals use the genre of case presentation to communicate among themselves the salient patient information during treatment and management. In case presentation, many uncertainties surface, regarding, e.g., the reliability of patient reports, the sensitivity of laboratory tests, and the boundaries of scientific knowledge. The management and portrayal of uncertainty is a critical aspect of professional discourse. This paper documents the rhetorical features of certainty and uncertainty in novice case presentations, considering their pragmatic and problematic implications for students’ professional socialization. Thisstudywasconductedduringthethird-yearinpatientclerkshipatatertiarycare,pediatrichospitalinhospitalin Canada. Data collection included: (1) non-participant observations of 19 student case presentations involving 11 student and 10 faculty participants, and (2) individual interviews with 11 students and 10 faculty participants. A grounded theory approach informed data collection and analysis. Fivethematiccategoriesemerged,twoofwhichthispaperconsidersindetail:‘‘ThinkingasaStudent’’and‘‘Thinking as a Doctor’’. Within these categories, the management and portrayal of uncertainty was a recurrent issue. Teachers modeled central features of a ‘‘professional rhetoric of uncertainty’’, managing uncertainty of six origins: limits of individual knowledge, limits of evidence, limitless possibility, limits of patient’s/parent’s account, limits of professional agreement, and limits of scientific knowledge. By contrast, students demonstrated a ‘‘novice rhetoric of uncertainty’’, represented by their focus on responding to personal knowledge deficits through the strategies of acknowledgement, argument, and deflection. Some students moved towards the professional rhetoric of uncertainty, suggesting not only advances in communication, but also shifts in attitude towards patients and colleagues, that were interpreted as indications that this rhetoric shapes professional identity and interactions. r 2002 Published by Elsevier Science Ltd. Keywords: Medical education; Clinical discourse; Identity formation; Canada Introduction Attitude and action in medical discourse Acute-care medicine is fundamentally about action. Doctors must act to intervene in a patient’s clinical course, and such intervention depends on the intersec- tions of three fundamental attributes: knowledge (an understanding of relevant anatomical and biomedical domains), skill (an ability to perform required proce- dures) and attitude (an orientation or stance that facilitates the appropriate clinical action). Clinical training has traditionally tended to focus on knowledge and skill. Consequently, medical educators have paid little attention to how attitudes are reflected in and reproduced by their practices. Yet appropriate attitude is essential to effective clinical action. Oneattitudethat has drawnresearchattentionisthat of ‘‘uncertainty’’. The articulation of uncertainty as an *Corresponding author. Fax: +1-416-340-3792. E-mail address: lorelei.lingard@utoronto.ca (L. Lingard). 0277-9536/03/$-see front matter r 2002 Published by Elsevier Science Ltd. PII:S0277-9536(02)00057-6