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.
