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Up Front | August 2021

Be Confident?

“Ignorance more frequently begets confidence than does knowledge.” — Charles Darwin1

“I’m often wrong but never in doubt.” — Ivy Baker Priest2

The Dunning-Kruger effect is a type of cognitive bias that leads people with a poor ability to perform a task to overestimate their ability to perform that task.3 This human foible often results in humorous consequences. Consider, for example, the criminal case of McArthur Wheeler, who was arrested for robbing two banks while his face was covered in lemon juice. In a curious misunderstanding of its chemical properties and ability to function as invisible ink, he was confident that lemon juice would render him invisible to security cameras.4 If you’ve ever watched a movie and thought to yourself, “These people think they’re smart, and they have no idea they’re actually complete idiots,” then you’ve watched a depiction of the Dunning-Kruger effect at work.

I prefer the reciprocal interpretation of this effect: The better you get at something, the better able you are to assess whether you really are any good at it. The concept here is that, as you gain expertise, you become more discerning, critical, and likely to find subtle faults in your performance. This idea certainly holds true in many disciplines, including surgery. I’ve heard from many experienced and skilled surgeons that they thought of themselves as great surgeons earlier in their careers, only later to discover nuanced levels of excellence they didn’t even know existed. This is such a common observation that its absence should be a warning sign.

Surgical confidence is obviously important, but striking a balance between trepidation and overconfidence is critical. I have observed surgeons whose results could have improved from their achieving a better balance between these two extremes. If you think about it for just a moment, our profession is an odd one. It takes a confident individual to plunge a knife into another human being in pursuit of healing, and it takes a confident individual to convince a patient to allow it. Confident is perhaps the most flattering of several adjectives that could be used to describe surgeons.

Patients like confident surgeons who provide definitive recommendations and opinions, even though doing so is sometimes impossible. The last thing a patient wants to hear is that the solution to their problem is a complex and unknowable swirling sea of grey as opposed to a bedrock of black-and-white certainty. The trouble is that many problems are a sea of grey, and the more you know about those problems, the more you see that there are no definitive answers to them. The job of a surgeon is to digest the various nuanced uncertainties, disclose them to patients, and ultimately provide a confident recommendation on the best course of action.

That doesn’t mean we aren’t uncertain from time to time—and we should be. Dogmatic absolutism is generally the trait of either a rare genius who truly knows more than anyone else or, more commonly, from someone unwilling or unable to understand the situation completely. As surgeons, we must live with uncertainty while giving our patients the peace of mind that they crave and deserve. Maybe lemon juice will cover up that uncertainty. It’s worth a try.

Steven J. Dell, MD | Chief Medical Editor

1. Darwin C. The Descent of Man and Selection in Relation to Sex. John Murray; 1871.

2. Ivy Baker Priest Quotes. AZ Quotes. Accessed July 26, 2021. https://www.azquotes.com/author/25926-Ivy_Baker_Priest

3. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999;77(6):1121-1134.

4. Why losers have delusions of grandeur. New York Post. May 23, 2010. Accessed July 26, 2021. https://nypost.com/2010/05/23/why-losers-have-delusions-of-grandeur/

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