Medical training oftentimes relies on pattern recognition, which is necessary to develop an excellent clinician who is both efficient and precise. There’s a flip side, though. An over-reliance on pattern recognition can miss outlying cases or entrench misguided practices. In addition, the knowledge base of medicine is vast, covering different specialties that are—in their own individual right—constantly evolving. The shifting landscape creates “potholes” that are not always readily apparent. It’s inevitable that we’ll step in these potholes, but may not even recognize them or, even if we do, we may find it difficult to acknowledge them. Overconfidence is one difficulty in seeing these potholes or acknowledging them.
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ACEP Now: Vol 42 – No 02 – February 2023Balancing confidence with self-cognizance can make us better clinicians who evolve with the medical landscape. There is a power in recognizing there are—as Donald Rumsfeld would term “unknown unknowns.” It relies on being cognizant of medicine’s and our own limitations, aware of our own egos, and then implementing concrete strategies, such as cognitive pauses, case reviews, and seeking feedback.
Overconfidence in Medicine
Medical knowledge evolves at a rapid pace. Peter Densen, MD, estimated that the medical knowledge “doubling” rate was 50 years in 1950, seven years in 1980, and just three and a half years in 2010.1 It’s hard to imagine a physician being masterful in every diagnostic and therapeutic technique for every patient. It is even sometimes difficult for physicians to be aware of these knowledge gaps. Studies on overconfidence are present in physician imaging interpretation and diagnosis.2,3 In one study in the intensive care unit, clinicians who were “completely certain” of a clinical diagnosis for 126 patients’ causes of death were actually incorrect 40 percent of the time, confirmed by post-mortem autopsy.4
Another interesting aspect of overconfidence is the Dunning-Kruger Effect, first described in 1999 in studies of participants’ self-perceptions in areas of logic, humor, and grammar. Its simplified findings were that the less proficient one was, the more likely one was to overestimate their proficiency. This has been similarly demonstrated in medicine. Residents’ confidence or self-perception of their knowledge in areas of diagnosis and communication were overinflated to their actual demonstration in these areas, compared to attending physicians. Furthermore, lower-performing physicians tended to rate themselves higher than their peers.4–7
The landscape of medicine and its physician training have natural hurdles that make one prone to overconfidence, but sometimes for good reason. Physicians are trained in areas of pattern recognition, hearing a chief complaint, and coming to a hypothesis. Cognitive load and time spent are decreased as this pattern recognition of “fast thinking” leads a physician down a familiar pathway. To prevent overtesting and overconsultation, physicians must make a quick differential to focus diagnostics and treatment. Most of the time, the hypothesis is correct. However, relying on pattern recognition with blind confidence can lead to “early diagnostic closure,” the premature narrowing of diagnostic possibilities such that the patient’s true diagnosis is never considered. While testing may be done to confirm a diagnosis, there may also be confirmation bias or seeking data to confirm an inaccurate hypothesis.
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2 Responses to “Why Physicians Are Overconfident and How We Can Overcome It”
March 5, 2023
tom benzoniDr. Koo
Thank you for a concise and thoughtful essay. It is a needed check. I especially like the cognitive pause, to ask WECIB (What Else Could It Be?)
I am entering my 5th decade in EM; I would be interested in thoughts on the flip side. Once you/I have seen a lot of cases and, yes, caused a lot of harm, we’re less certain.
For example, some EPs are confident in TPA for stroke, not aware they are observing the natural history of many strokes as well as seeing stroke mimics. That confidence takes a hit when they injure a patient with a bleed that would not have otherwise occurred. Confidence weakens further when, with followup (rare now that we use EBRs (Electronic Billing Records) that have to be closed by end of shift), we discover the patient had a stroke mimic and could not possibly benefit from our therapy but they could/did for sure suffer harm.
Thus a thought: enjoy the over-confidence. It is a luxury that, should you survive long enough in EM, will be regarded in the rear-view mirror with fond indulgence.
July 17, 2024
Alex KooDr. Benzoni,
Thank you for a really insightful perspective and realized this is a late comment to your post, so apologies. Honestly, I didn’t know comments were even a thing for the ACEP Now articles so thank you for it!
“Enjoy the overconfidence” is a great pearl and I’ve taken that one to heart. I’ve interpreted your wise line as a reminder to reflect earnestly – non-critically and non-judgmentally.
The “overconfidence” in certain scenarios will be inevitable, particularly with nuanced or novel cases when there are unseen potholes. And to your point, I could see residency as a safer environment for understanding overconfidence and learning from cognitive errors. The resident is allotted this luxury under supervision and honestly, it can be argued that only through “pushing the envelope” of one’s abilities can one learn. Feigning confidence is sometimes the necessary impetus to say, “this angioedema patient needs a cricothyrotomy” before it’s too late. “Analysis paralysis” will always be the flip side of overconfidence and can be to the patient’s detriment.
I really appreciate your wisdom and thoughtful insight – I would look fondly on an earlier self and sometimes, see a reflection of the same in the residents we have the opportunity to work with!