4. Review patient cases.
Whether through following patients seen on a prior shift, video review of a resuscitation, or reviewing cases on a committee, seeing your own and others’ practice patterns can reveal improvements in practice that weren’t apparent before.
Explore This Issue
ACEP Now: Vol 42 – No 02 – February 20235. Learn from others and ask for feedback.
Learn from those around you through observation, asking them of their cases, and asking for effective feedback. “Signout time” may be a good opportunity to learn from colleagues’ thought processes for a common patient. When asking or giving feedback, use the “SMART” mnemonic: specific, measurable, attainable, relevant, and timely.10
6. Foster a supportive and reflective environment.
Mitigating overconfidence is not just an individual task but an institutional task. Without institutional support and safe feedback mechanisms, a culture of overconfidence can be perpetuated. Clinical decision aids can be used to guide clinicians in their thought process and promote cognitive pauses. Measurable standards such as goal patients/hour or 72-hour repeat ED visits should be transparent to clinicians with scheduled feedback in a safe and nonjudgmental environment.
Sometimes, it can be sobering and tiring to always be introspective and mindful of your limitations. However, the better “you” has always been there in satisfying a curiosity, whether it’s learning a new technique or rethinking your approaches. Even Socrates, a symbol of wisdom, posited that his wisdom came from his recognition of his own ignorance. He wisely mused, “I know that I know nothing.”
Dr. Koo is faculty and an emergency physician at MedStar Washington Hospital Center in Washington, DC and St. Mary’s Hospital in Leonardtown, Maryland. He is an assistant professor of emergency medicine at MedStar Health and Georgetown University Hospital and adjunct assistant professor of military and emergency medicine at the Uniformed Services University of the Health Sciences.
References
- Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.
- Berner E, Graber M. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121: S2-S23.
- Schauer GF, Robinson DJ, Patel VL. Right diagnosis, wrong care: patient management reasoning errors in emergency care computer-based case simulations. AMIA Annu Symp Proc. 2011;2011:1224-1232.
- Podbregar M, Voga G, Krivec B, Skale R, Parežnik R, Gabršček L. Diagnostic accuracy in the medical intensive care unit – critical care. BioMed Central. https://ccforum.biomedcentral.com/articles/10.1186/cc3874#citeas. Published March 2, 2001. Accessed January 25, 2023.
- Friedman CP, Gatti GG, Franz TM, et al. Do physicians know when their diagnoses are correct? Implications for decision support and error reduction. J Gen Intern Med. 2005;20(4):334-339.
- Rahmani M. Medical Trainees and the dunning-kruger effect: when they don’t know what they don’t know. J Grad Med Educ. 2020;12(5):532-534.
- Lam JA, Feller E. Are we right when we’re certain? overconfidence in medicine. R I Med J. 2020;103(2):11-12.
- Flynn D, Knoedler MA, Hess EP, et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012;19(8):959-967.
- Yagil D, Yehudit R, Dikla S. Physicians’ cognitive strategies for avoiding overconfidence. Journal of Evaluation in Clinical Practice. 2021;(4):935–941.
- Moore K. Giving S.M.A.R.T. feedback to millennials. Forbes. https://www.forbes.com/sites/karlmoore/2014/12/04/giving-s-m-a-r-t-feedback-to-millennials/?sh=44744a9071d3. Published December 5, 2014. Accessed January 25, 2023.
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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!