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.

Balancing 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.

Lastly, there are societal and internal pressures that feed into an unrealistic visage that physicians cannot make mistakes. As a result, we may internalize and overestimate our professional competency. On top of that, it is just naturally difficult to admit or confront one’s own mistakes. Sometimes it feels better to feel right than to be right. These pressures create obstacles for one to self-evaluate their performance critically and accurately.

Strategies for Combating Overconfidence

1. Identify knowledge gaps and create a plan to fill these gaps.

Recognize that the practice of medicine has limitations. Even with the latest evidence and training, there will always be a level of uncertainty. One established practice pattern today may be altered or completely refuted in a few years. Be open to the possibility of change.

Honestly evaluate yourself. Make a list and be specific. Look at your strengths. If  electrocardiogram interpretations are a strength, why do you believe it is a strength? What strategies have you employed to create it as a strength? Are there any uncertainties to resolve? Then, look at what may be needed to make an area of improvement into a strength. If point-of-care echocardiograms are a weakness, be specific. Is it looking for right heart strain or looking for regional wall motion abnormalities? Then, create a plan of action to improve these areas—do a review of literature, watch videos, take a course, practice with simulation, and implement into your real-time practice.⁸

2. Frame your professional identity and motivations.

Framing a growth mindset to emphasize pride in effort rather than pride in skill or status can combat pitfalls of overconfidence. To say, “I value the courage to admit mistakes, continual learning, and the effort to improve” over “I value my accolades, accomplishments, and titles” can be a powerful shift.⁹

3. Implement cognitive pauses.

“Cognitive pauses” are deliberate interruptions in your workflow to apply critical thinking or reevaluate available data. In medicine, cognitive pauses can be used to critically assess available lab results, imaging, challenge one’s own final diagnosis, and/or reaffirm the possibility of overconfidence. What results do not fit with my diagnosis? Are there alternative diagnoses I have not considered? Cognitive pauses can be applied in a nondiscriminatory or in a situation-dependent fashion. For example, a “blanket” cognitive pause can be applied prior to every patient discharge or situation-dependent one when encountering an unfamiliar or very complex case.

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.

5. 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

1. Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.
2. Berner E, Graber M. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121: S2-S23.
3. 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.
4. 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.
5. 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.
6. 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.
7. Lam JA, Feller E. Are we right when we’re certain? overconfidence in medicine. R I Med J. 2020;103(2):11-12.
8. 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.
9. Yagil D, Yehudit R, Dikla S. Physicians’ cognitive strategies for avoiding overconfidence. Journal of Evaluation in Clinical Practice. 2021;(4):935–941.
10. 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.