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Diagnosis

Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

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Balancing confidence and humility in the diagnostic process

Jianni Wu / Eve LowensteinORCID iD: https://orcid.org/0000-0002-9934-860X
Published Online: 2019-06-29 | DOI: https://doi.org/10.1515/dx-2019-0037

Abstract

Humility in medicine can be difficult to achieve, yet arguably is one of the most important competencies to master. Overconfidence, on the contrary, is a natural tendency, having established its roots in evolution where quicker and more confident decisions likely conferred a selective advantage. Moreover, humility may evoke an image of weakness and vulnerability, antithetical to contemporary medicine, whose culture is dominated by overconfidence. Nevertheless, humility can be learned, and is important because overconfident behavior can be detrimental to our patients medically, psychosocially and legally, when it results in delayed or missed diagnoses. To achieve humility requires a great deal of metacognition, normalizing doubt and not being afraid to utilize tools that may feel beneath us. To practice humility requires strength and emotional resilience. In this paper we explore the definitions, roles and implications of humility in medicine, and we pose suggestions of how to accomplish this in the diagnostic process.

Keywords: humility; overconfidence

“Knowledge is proud that it knows so much; Wisdom is humble that it knows no more.” – William Cowper [1]

Introduction

Medical humility was already a hard sell in 1906, when Sir William Osler tried to give it a “place of honor” among medical virtues [2]. We live in a culture where arrogance, assertiveness and entitlement are modeled by some of the leadership at the top and by some of the most famous and highly paid celebrities and athletes. What is more, we are surrounded by media personifications of physicians who seem to know it all (House), are geniuses despite limited life experience (Doogie Houser) and are always in charge, sexy and self-confident (Grey’s Anatomy). Where does that leave humility in medicine today? While compassionate care is a universally acknowledged ideal, the principles associated with prudence and humility are less popular [2]. This paper explores the definition(s), role and implications of humility in medical practice. We make a case for humility as perhaps the most difficult virtue to understand and practice, while perhaps the most crucial to achieve. Humility, like any muscle, can be strengthened through exercise, practice and training. Suggestions in developing a poise of humility in the diagnostic process are described.

Barriers to humility

Doubt is a skill. Credulity, by contrast, appears to be something like an instinct” – Kathryn Schulz [3]

Overconfidence – a miscalibration of one’s own sense of accuracy versus actual accuracy – is a natural tendency in humans [4]. For example, in a survey of drivers, only 1% of drivers rated their skill below that of an average driver [5]. Similarly, in a survey of academic professionals, the overwhelming majority (94%) rated themselves in the top half of their profession [6]. An attitudinal tendency toward overconfidence likely has prevailed because it confers a selective evolutionary advantage, leading to less indecision and more definitive action [7]. Equivocation can lead to extinction, whereas those who instinctively made quicker decisions and acted upon them increase the chances of their genes surviving into the next generation. Thus, a clinician who appears unsure in front of a patient may signal weakness and vulnerability. Moreover, studies have shown that patients are more likely to question the competence of doctors who too quickly acknowledge their own limitations [2].

Another, perhaps more simple reason overconfidence has prevailed may be in part explained by the phenomenon of “error blindness”, which is to say, until proven wrong, we feel right [3]. Our steady state unconsciously assumes that we are omniscient [3]. It is, therefore, no wonder that the ideal image of a “good physician” is one that projects confidence, skill and assertiveness.

Sources of overconfidence

“What screws us up most in life is the picture in our head of how it is supposed to be.” – Socrates [8]

A lack of feedback is probably the most significant promoter of overconfidence [9]. For example, in a study using autopsy findings – a powerful learning tool and medical gold standard – physicians’ confidence level of an ante-mortem clinical diagnosis showed no correlation with accuracy [10]. This finding is further supported in another retrospective chart review, where autopsy rates in an intensive care unit setting were higher in groups with greater diagnostic uncertainty, however, there was no correlation between the level of diagnostic certainty and the rates at which potentially treatable errors occurred [11]. Similarly, Ioan et al. found that the concordance rate of clinical and forensic pathologist diagnosis is 45% [12]. The decline in autopsies over the last few decades contributes to overconfidence by failing to detect and teach from errors, thus contributing to clinicians’ distorted views of their own error rates [13].

Yet, specialties, such as dermatology, that are uniquely positioned with the advantage of receiving rapid feedback on diagnostic acumen through histopathology, are also not free of the interference of overconfidence. For example, overconfidence as a source of error was demonstrated in a study where experienced dermatologists missed the correct diagnosis of melanoma 45% of the time [14]. Another study showed dermatologists to be confident in the diagnosis of melanoma in >50% of test cases, but were wrong in 30% of these decisions [15]. In a separate study, pathologists altered the diagnosis of melanoma on a second review 11% of the slides [16].

Furthermore, a culture of silence and fear of consequences has interfered with readiness to give and accept feedback [9]. While one would think humility would surface with lack of experience and absence of dogma, this has not generally proven to be the case. Overconfidence has been found to be more frequent among novices than experienced physicians [17]. In a study where board-certified radiologists were given a set of unknown films to discern normality, confidence levels were actually higher in the worst performers compared to the top performers [18]. Sanchez and Dunning termed this the “beginner’s bubble” of overconfidence, a phrase used to describe the phenomenon of perceived accuracy (i.e. confidence level) quickly outpacing actual accuracy once a little bit of information has been gathered [19]. True expertise, however, has been linked with appropriately modulated confidence levels [4].

Diagnostic overconfidence can be cognitive or attitudinal. Cognitive overconfidence – when the physician believes he or she has the correct diagnosis without adequate investigation or analysis – is an intellectual presumptiveness, which occurs due to faulty heuristics or “cognitive dispositions to respond [20]”. These cognitive errors can result from a failure to elicit a complete and accurate history, to recognize the importance of a piece of information or data, or simply a failure to synthesize the information [21]. A failure to implement metacognition – critical examination of one’s own assumptions, beliefs, thought processes, and conclusions – is often responsible for this source of diagnostic error [21].

Attitudinal overconfidence can involve complacency or arrogance. Complacency represents an attitude of status quo: a lack of intellectual curiosity and knowledge-seeking behavior. Likened to the Christian deadly sin of sloth (and perhaps deemed equally a source of evil), complacency is characterized by a lack of engagement in or resistance to feedback in diagnostic reasoning. Studies show an active disinterest in diagnostic and therapeutic support, suggestive of pervasive complacency in medicine. In one study, physicians admit to having many questions that are important in the care of their patient, which they do not pursue [22]. This is true even when the resources are automated and easily accessible with a computer [23]. Moreover, research related to physician response to clinical guidelines found that the care provided deviates from the recommended best practices about half the time [24].

Arrogance is another source of attitudinal overconfidence. In a physician’s role as healer, it is understandable how possession of power and knowledge can offer an opportunity to delude oneself to feel more powerful than they are. Adding to this, the emotional collusion of a sick patient’s wishful thinking of a doctor as an omnipotent/omniscient figure (often in proportion to the gravity of their disease) may foster a latent arrogance [25]. Furthermore, the promotion of emotional detachment as a requisite for objectivity in our profession may serve to foster a non-reflective poise. In today’s medical education, technical skills have emerged as fundamental and stressed in the tacit value system of our field, whereas interactive skills, intellectual modesty and self-effacement are seen as secondary [26], [27]. Finally, in our healthcare system where physicians and patients are the provider and healthcare consumer, respectively, the doctor-patient relationship has become commercialized and depersonalized, breeding a system arrogance dehumanizing of physicians and patients alike [25].

The value of humility

“It is ultimately wrongness, not rightness, that can teach us who we are.” – Kathryn Schulz [3]

While confidence is needed to engender the trust of a patient, overconfident behavior can be detrimental to our patients medically and psychologically with legal ramifications, when manifest in the context of delayed or missed diagnoses. Humility, on the other hand, acknowledges the ambiguities, uncertainties and surprises inherent in the world. Humility is the trait that allows one to appreciate the limits of ones’ abilities, understanding and importance. It requires strength and emotional resilience.

Alfano et al. have developed and validated a four part tool for measuring intellectual humility, including open-mindedness, intellectual modesty, corrigibility, and engagement [28]. While desirable and noticed by patients and colleagues alike, humility is still difficult to measure, is generally undervalued, and is not a marketable virtue per se. That being said, modern medical education is structured around the development of certain core competencies, including professionalism, which itself cannot be achieved without humility [2]. In fact, it has been suggested that humility should be at the top of the list of desirable professional attributes in applicants for residencies [29].

Self-reflection and self-critique

“Klosterman’s razor: The best hypothesis is the one that reflexively accepts its potential wrongness to begin with” – Chuck Klosterman [30]

The starting point for humility is self-awareness [30]. We all have knowledge gaps that prevent us from recognizing our errors and leave us unlikely to ask for help. However, knowledge is essential in order to focus on our blind spots. Known as the Dunning-Kruger effect, one has to know something in order to appreciate what one does not know [31]. This intellectual humility (i.e. knowing what we do not know) is a key driver committing physicians to the lifelong pursuit of knowledge [31]. Knowing even a little is the gateway to learning more, thus one cannot be properly humble without knowledge.

We could know, and should know, but don’t know because it makes us feel better not to know.” – Margaret Hefferman [32]

Achieving cognitive humility is more easily said than done. While most of reality can be likened to a puzzle with missing pieces, we tend to willfully ignore what we do not see and find it ubiquitously difficult to accept our ignorance [32]. Introspection is essential, but generally devalued in medical education, with the emphasis on teaching facts or technical skills. Metacognition, thinking about how we think, is essential in avoiding diagnostic error and requires considerable introspection. For example, the very consideration of diagnoses as definitive tags rather than as evolving hypotheses encourages an intellectual presumptiveness. Medical knowledge is always tentative and incomplete [33]. Thinking about diagnoses as hypotheses of various confidence would be more accurate, honest and encouraging of suitable confidence.

Making doubt acceptable

“Doubt is not a pleasant condition, but certainty is absurd” – Voltaire [34]

While one may be very confident with the familiar, confidence may appropriately plummet when treating the complex and rare. Most medical practitioners appreciate limitations when encountering unsolvable problems or un-savable patients. And yet, the proper calibration of confidence is not always simple. Recognizing the zebra (unexpected, rare) diagnoses for what they are and approaching them with greater caution and less confidence is appropriate.

“Those who travel with the current will always feel like they are good swimmers; those who swim against the current may never realize they are better swimmers than they imagine.” – Shankar Vedantam [35]

Furthermore, one’s sense of their ability may vary directly with the diversity of their practice. However, even if one practices within a narrow subspecialty and comfort zone, there will always be the unknown and unknowable. In fact, the more rare or difficult the case, the greater the humility required. Harboring a sense of ignorance, even stupidity, can liberate us from awkwardness when delving into the unknown diagnoses.

Things that may feel beneath us, but are not

With the current expansion of knowledge and technology in medicine today, any individual doctor’s capacities to care for patients can be rapidly overwhelmed. Physicians may resist many new tools available that seem beneath them, for fear that these may make them appear like automatons or cogs in a machine, but many of these tools have provided evidence of improved care. Examples include the use of surgical checklists [36], [37], computer-aided melanoma diagnoses [38] or diagnostic decision support systems and artificial intelligence [39], [40]. Other practical suggestions to improve diagnoses, which require appropriate humility include simple approaches such as expressing findings and verbalizing the differential diagnoses, and getting a second opinion, are reviewed elsewhere [41], [42], [43].

Proper modulation of self-interest and fostering a team approach are also more important than ever. “Health care today needs pitcrews, not cowboys” [44]. The entire medical team, including administrative and nursing staff, impact patient care. While there is a paradoxical tension between self-interest and altruism, physicians need to maximize altruistic behavior while acknowledging personal needs and limits. Humility facilitates altruism and down-regulation of personal interests such as convenience, peer approval, pleasure, financial gain, fame, power or prestige. Modulation of self-interest can be achieved with a keen appreciation and gratitude for the privilege of caring for others.

Other learning sources

One of our greatest learning tools is from patients themselves. To be a patient is to be humbled by circumstance, in a state of vulnerability, with independence undermined and a reduced sense of self, control and even hope. It has been said that physicians who lack humility talk at patients, whereas humble physicians speak with patients. By listening to our patients, we engender empathy [45]. A sense of gratitude in serving our patients is a mark of internalized humility.

Conclusions

The contemporary view of the physician is often skeptical of seeming too weak or wishy-washy. Yet the medical, psychological, and legal ramifications of diagnostic error behooves us to find the courage and resilience to focus on practicing medicine with humility. Approaching patient care from this position can help physicians consider broader differentials, reexamine difficult cases, refrain from complacency and acknowledge that learning in medicine is indefinite and lifelong.

Humility, a cornerstone of professionalism, is perhaps the hardest competency to achieve. However, with awareness, desire and veneration for humility, physicians can guard against the innate contrary tendencies. Keeping in mind that diagnoses are hypotheses helps to keep us humble. Emotionally acknowledging and internalizing that we are privileged, rather than entitled to practice medicine frames our role in a grounded way. And perhaps, most potent is the realization that little separates us from our patients; that we all will, at some point, be patients.

References

About the article

Corresponding author: Eve Lowenstein, MD, PhD, SUNY Health Science Center at Brooklyn, Kings County Hospital Center, Brooklyn, NY, USA; and Associate, South Nassau Dermatology PC, Oceanside, Long Beach, NY, USA


Received: 2019-05-12

Accepted: 2019-06-07

Published Online: 2019-06-29


Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


Citation Information: Diagnosis, 20190037, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2019-0037.

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