Thursday, January 12, 2017

Medical Education: The Confident but Incompetent

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Author: Michelle Mitchell MS-IV
Geisinger Commonwealth School of Medicine
Scranton, PA
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In 1995, a 44-year-old man named McArthur

Weeler devised the perfect plan to rob a bank. Wheeler knew (or supposedly knew) a lot about the chemical properties of lemon juice. As is taught in grade school science class, lemon juice can be used to create invisible ink. With this logic, Wheeler thought that by smearing lemon juice on his face, he would become invisible to the security cameras at the bank. He confidently walked into two banks in Pittsburgh, robbed them, and was promptly caught hours later when the security video aired on the news. When Wheeler was apprehended, he could not believe it. “But I wore the juice,” he puzzlingly mumbled.[1]

This story was the inspiration behind psychological experiments carried out by David Dunning and Justin Kruger of the Department of Psychology at Cornell University.[1] In essence, their question pondered, are the stupid too stupid to realize they are stupid? More eloquently, the article states:

“People tend to hold overly favorable views of their abilities in many social and intellectual domains. The authors suggest that this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden: Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it.”

Dunning and Kruger designed experiments to test their theory on Cornell undergraduate students enrolled in psychology courses. They gave the students a series of tests on logical reasoning skills, grammatical skills, and humor. After completing the test, the students were asked to estimate their performance compared with their peers. Their researched illustrated two important points. First, the poorly performing students overestimated their abilities. As Dunning and Kruger noted, “Across four studies, the authors found that participants scoring in the bottom quartile … grossly overestimated their test performance and ability. Although test scores put them in the 12th percentile, they estimated themselves to be in the 62nd percentile.” The second point of the article illustrated that the opposite was true of high performers; they underestimated their abilities. Since the task was easy for them, they assumed it was easy for everyone as well.

We all know someone, whether it is a medical student, a team member, or a physician colleague who overinflate their perceived clinical competence, ability to connect with patients, or teaching abilities. Based on the aforementioned psychological experiment, there’s a name for that – the Dunning-Kruger Effect. As competent and confident physicians, how do we prevent ourselves from becoming part of the Dunning-Kruger Effect?

Most physicians would agree that it is vital to question thought processes. Why is this patient’s chest pain likely caused by a myocardial infarction? Why can’t it be a pulmonary embolism? What in the patient’s story does not match the clinical gestalt? Look for potential flaws in the underlying thought process, and recognize how inherent biases could cause unsound logic. Additionally, as much as possible, try to follow up on admitted patients. Was the patient correctly diagnosed? Did the inpatient team switch to a different (and perhaps more evidence-based) antibiotic? Another way to improve clinical competence is to seek mentorship. As Atul Gawande pondered in his article “Personal Best,” why do other professions, such as professional singers and top athletes, have coaches, but physicians do not?[2] Ask coaches and mentors to observe you in action, whether it is repairing a laceration or obtaining an history and physical. You may be surprised at how small changes in daily practice can impact outcomes. Then, revisit the provided feedback and focus on your greatest weaknesses. At the beginning of your next shift, ask the attending physician for feedback on a weak area, for example, discharge disposition. This will provide the attending physician time to develop specific, actionable feedback throughout the duration of the shift – while avoiding generic, vague feedback that is oftentimes not helpful.

If you ever question your competence during the day, or perseverate over your ED management of patients, you’re likely not part of the Dunning-Kruger Effect. The ability of a physician to understand his or her own limitations in knowledge requires a degree of introspection and self-awareness. A physician questioning her thought processes and actions means she is likely aware of these limitations. A powerful litmus test is to ask oneself a single question. When was the last time I told a patient “I don’t know”? As Confucius once said, “Real knowledge is to know the extent of one’s ignorance.”


1. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of personality and social psychology. Dec 1999; 77(6):1121-1134.

2. Gawande A. Personal best. Top athletes and singers have coaches. Should you? [Annals of Medicine] The New Yorker. 2011. Oct 3, Available at: Accessed October 1, 2016.

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