The Difference Between Confidence and Competence: Growing with a Confident Humility

Originally publishsed in the June 18, 2021 issue of the Transformational Times

 

The Difference Between Confidence and Competence: Growing with a Confident Humility

 

 

Adina Kalet, MD MPH

 

 

Dr. Kalet shares one of the “hidden” tasks that each new resident faces: the need to develop competence without risking becoming overconfident. In this encore essay, she shares some of the pitfalls and invites housestaff to be part of the journey ...

 

 

“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.” 

- Mark Twain

Thousands and thousands of newly minted physicians begin residency training each year. At MCW, we welcomed our new residents in July, many of whom movied 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 embark 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 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 in 2019. 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. 

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 house staff, I say, “You've got this!” 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.

Fellowship Training: Mindfulness, Coping, and Lymph Node Dissections

From the April 21, 2023 issue of the Transformational Times

Fellowship Training: Mindfulness, Coping, and Lymph Node Dissections 

Lindsey A. McAlarnen, MD, M.Sc. 

 

Dr. McAlarnen is completing her three-year Gynecologic Oncology fellowship at MCW. Along the way, she has been involved in the REACH Curriculum and the Kern KINETIC3 Teaching Academy. In this essay, she reflects on her three-year journey, including learning to pause for mindfulness as a busy physician and surgeon, and offering some words of thanks... 

 

A few weeks ago, my co-fellow and I joked about how different fellowship was from residency. 

 

Catching two clinical fellows sitting in our shared academic office is a rare event. Our office is more of a glimpse into the day a co-fellow is having than a gathering space. Lukewarm, once-iced coffee sitting on a desk, a cold breakfast sandwich with one bite taken, or empty research tubes set on the keyboard as a tangible to-do message from the clinical research team, are unwritten memos of leaving in a rush to “take care” of a clinical event or dashing to the OR. 

 

I grew to tangibly feel in my body what my co-fellows were experiencing by reading their eyes through a face shield and mask in the OR, or by translating the nearly untouched Starbucks drink on their desk. 

 

This common bond led to a great understanding and moment of mutual appreciation when I muttered, off-the-cuff, that my experience of gynecologic oncology fellowship is basically a lesson in “Mindfulness, coping, and lymph node dissections.”  

 

Coping came first—starting fellowship in a new program at MCW as the first fellow ever in July 2020—was quite an experience. I graduated from OBGYN residency on a Friday, moved to Milwaukee Saturday, and came to the Froedtert/MCW campus Monday to get my ID badge and tour the OR. There were scant orientation modules, no in-person meetings, and after being brought to the 4 Pavilion nursing unit, I was sent on my way to being the first gynecologic oncology fellow. With little direction and no one ahead of me, I learned mostly through missteps or what I did wrong. 

 

Enjoy the little things in life because one day you’ll look back and realize they were the big things.  

– Robert Brault 

 

What I do—and do not—remember from my first year of fellowship

I block out the majority of memories from that first year of fellowship—as a protective mechanism. When I reflect on it, I don’t know how I survived being on-service for ten months, with "breaks" for rotations in the surgical ICU and with radiation oncology. 

 

I do remember and reflect on what got me through this time—my mom’s meal prep sprints that stocked the freezer after Christmas, my high-school-aged neighbors whom I employed to walk my dog daily, and whenever I got stuck at the hospital late. I remember first feeling a part of the team after joining the surgical ICU service in October of 2020—our collective sense of the unknown as we read news details of protests in nearby Wauwatosa—and mentally preparing for the possibility of an increased ICU patient census.  

 

During my research year of fellowship, I had the chance to engage in various teaching opportunities, the most rewarding of which was serving as clinical faculty for a small group of M1-M2s in the REACH (Recognize, Empathize, Allow, Care, Hold) curriculum. This experience represents a turning point for me, an introduction to mindfulness as a part of my clinical practice, and the point in my training—albeit as a PGY6—where I learned to pause and incorporate awareness into my usual tasks as a busy physician and surgeon. When I think of the whole of REACH, the amazing students it introduced me to, and Dr. Cassie Ferguson, the meme or car magnet of adopted pets comes to mind: “Who rescued whom?” 

Putting mindfulness into action

Back in the clinic, wards, and operating rooms this academic year, I have a different appreciation for my patients, colleagues, and faculty. Trying to practice mindfulness in clinical practice is a work in progress for me, but I have been able to take ‘memory snapshots’ throughout the year that serve to reinforce the reasons I went into medicine, my subspecialty, and function as pearls of inspiration for the tough times. 

 

The snapshots most frequently involve images of relationships I’ve made—like with the 4P charge RNs and our daily morning ‘RTL’—run the list—through the nurse’s station window—or counting on the smile and predictable greeting of the employees who passed out stickers granting access between Froedtert and the HUB during 2020-2022.  

 

When I reflect on these relationships and snapshots, I often recount the hundreds of people who have helped me reach this point in my career. From my 2nd grade teacher at summer writing camp to the undergrad advisor who I distinctly remember telling me, “People like you don’t get into medical school,” to my medical school classmates who are each doing different, yet amazing things every day in their own practices across the world—each has had a profound impact on my knowledge base and training, but more importantly on my character as I grew from a fifth-grader dreaming of being a pediatric orthopedic surgeon to a thirty-something gynecologic oncologist.  

 

The summation of these experiences and relationships shaped me—both the good and the bad—and I hope to continue to grow and evolve as a person and surgeon throughout my career.  

 

You see things, and you say, "Why?" but I dream things that never were, and I say, "Why not?"

 – George Bernard Shaw 

 

That I am almost a fellowship-trained gynecologic oncologist is hard to fathom. As a resident at Loyola University Medical Center, gynecologic oncology seemed like the ultimate specialty to me. The Gyn Onc faculty expected us to treat critically ill patients, perform bedside procedures, assist on debulkings to R0 (surgically removing all evidence of residual cancer), understand the evidence behind basic treatment of the most commonly diagnosed GYN malignancies, and have a bedside manner and relationship with patients in the clinic such that they saw you as "their doctor." 

 

Thoughts as I complete my fellowship

Looking at my three faculty from residency, I never imagined I could be them someday. I doubted my ability to learn the chemotherapy and radiation techniques needed to treat gynecologic malignancies; the amount of clinical acumen required scared me. To the mentor who said, “You can,” thank you for believing in me.  

 

Surgery is a whole different ballgame. My goal during my chief year porcine lab was to laparoscopically remove a lymph node, and my "graduation present" was being granted the opportunity to fire an EEA stapler.

Now these memories make me laugh. Lymph node dissections of the pelvis and para-aortic region are the cornerstone of Gyn Onc fellowship. I’ve learned and removed lymph nodes via laparotomy, robot, and laparoscopically. The technique requires dexterity, precision, and there are multiple “correct” ways to perform a lymph node dissection.  

 

I’ve come a long way surgically during my fellowship, and I appreciate every surgical assist, tech, circulator, member of the anesthesia team, faculty, resident, student, environmental services staff member and, most importantly, every patient who has provided manual assistance, tips, tricks, or opportunities to operate and teach in the OR. The OR has been described as "the most vulnerable place in the hospital," and I can appreciate this statement from the perspective of both the patient and the surgeon.  

 

To those who have watched me struggle, become frustrated, or be unable to accomplish something, thank you for your patience. To the great surgeons who have shared their technique and strategy, thank you for your wisdom. To the few who have shared the lessons they have learned in the OR from their own mistakes and surgical growth, this has contributed the most to my professional development as a surgeon. Thank you. 

 

Surgery requires diligent reverence. May I go forth from my training to mindfully operate and teach those with gynecologic malignancies and those caring for them. 

 

 

Lindsey A. McAlarnen is a third-year fellow in the Division of Gynecologic Oncology in the Department of Obstetrics and Gynecology at MCW. She is a member of the KINETIC3 Medical Educator Track.