From Medical Student to Trusted Physician: Growing with a Confident Humility

 From the 6/18/2021 newsletter

Director’s Corner

 

 

From Medical Student to Trusted Physician: Growing with a Confident Humility

 

 

Adina Kalet, MD MPH

 

 

Dr. Kalet shares one of the “hidden” tasks that each new resident is facing: the need to develop competence without risking becoming overconfident. She shares some of the pitfalls and invites our newest house staff to be part of the journey.

 

 

This is the time of year when thousands and thousands of newly minted physicians move somewhere to begin residency training. At MCW, we welcome all our new residents, many of whom are moving to Milwaukee for the first time. This is a poignant, anxiety-provoking, and exciting time, a new beginning, and a critical transition on the journey of becoming a seasoned and caring physician.

 

Incoming residents are embarking on the steepest leg of their learning curves. Not only have many of them just moved to a new city, found a new home, and located a new grocery store, each new day brings them an avalanche of firsts: the first patient, the first procedure, and the first time they need to find the cafeteria or the bathroom or the emergency room. Many important components of their new professional identify will take shape in these first summer weeks. Our newest physicians will work to discern how best to balance confidence and humility. Getting this equilibrium right is crucial, and I think MCW is an especially wonderful place to foster this process.

 

The difference between confidence and competence

As physicians on the front line, residents are expected to develop enough confidence to quickly analyze data, make crucial decisions, and act decisively. Think about how difficult and fraught that task can be! We want physicians to make critical judgements under emotionally charged and complex conditions. Even drawing blood for routine laboratory testing (a task interns do daily) means facing an anxious, fearful, suffering person, and causing them some pain. Confidence is critical, yet—to ensure that our teams provide the highest quality and safest health care—we stay on the lookout for overconfidence in ourselves and in others because of the complex and paradoxical relationship between confidence and competence.

The Dunning-Kruger effect, described in 1999, elegantly summarizes this complexity. Stated simply, people with low ability tend to overestimate their competence and, therefore, become overconfident. Conversely, people with high ability tend to be underconfident in their ability. Even worse, poor performers are often unable to recognize their own limitations, and overconfidence is especially pronounced for those at the lowest end of the ability scale. As ability improves with practice, confidence, paradoxically, can take a nose-dive because the difficult journey can create humility and self-awareness. This sense of deflation can feel terrible at the time but, in the long run, is good since it can lead to insight and growth.  

Numerous studies have confirmed that humans are just not good at objectively evaluating their own level of competence, but by honing one’s own metacognitive awareness or being observant—like a scientist—of one’s own thinking and feeling, a novice can guard against using his or her own confidence as an indicator of competence. As teachers, we must avoid making our trust judgements based on a trainee’s confidence alone. As Ronald Reagan was wont to say, we must, “Trust but verify.” Confidence is good, but we must guard against allowing our feelings of confidence to blind us to our own ignorance.

 

 

“Confident humility”

 

In his new book, Think Again: The Power of Knowing What You Don't Know, organizational psychologist Adam Grant reminds us how critical it is to cultivate a mindset “confident humility.” From this stance, one can act even when they are not certain of what is right, but they act with a scientist’s curiosity and perspective, seeking evidence that might refute their current beliefs. Grant reviews the accumulating evidence that intelligence does not protect us from common human foibles. In fact, many researchers have pointed out that smarter, more tenacious people (like many medical students and residents) are prone to blindness to changing conditions and may have a harder time adjusting to new circumstances. They have difficulty admitting when they are wrong. Stubborn, inflexible physicians will run into obstacles when trying to provide competent, character-driven medical care.
 
If, however, a hypothesis survives repeated attacks, it becomes the working theory until such time as it can be disproven. Approaching one’s own competence in this rigorous way—repeatedly challenging beliefs and understandings—keeps a person humble, curious, adaptable, and learning. It is the key to deep, durable, and lifelong learning. 

 

The remarkable value of working in an institution defined by confident humility

 

Like many of us, I am a transplant from elsewhere, having arrived barely two years ago. I have traveled extensively and have lived and worked in other institutions in the northern and southeastern United States. To my delight, I have come to know MCW as a uniquely confident, humble place to work and learn. It is remarkable to me—given the excellence in clinical care and research—how little our institution tolerates the everyday self-promoting arrogance typical at many of our peer institutions. This institutional culture is a towering strength and I believe is one of the many reasons we have adapted and thrived for a century and a quarter. 

As Mark Twain warned, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Adam Grant points out that a hallmark of wisdom is knowing when it’s time to rethink and collect data that might refute and, therefore, cause you to abandon what you think you know and who you think you are. This habit of honest reflection and an openness, or even a delight in learning when you are wrong, is a path toward a deeply satisfying confidence. It’s true in business and especially true in medicine.

 

So, to our incoming house staff, I say, “welcome!” You have several difficult tasks ahead, not the least of which is to master your chosen field. You will grow as you learn to work in teams, experience ambiguity, become lifelong learners, and bring your intellect and compassion together to tend the sick and heal the suffering. You will thrive if you tend to your own wellness and character. These are huge tasks responsibilities. We wish you all the best and are here to support you.

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.