Balancing confidence and humility in the diagnostic process
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Jianni Wu
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.
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.
References
1. Quote Fancy [Internet]. Available at: https://quotefancy.com/quote/758352/William-Cowper-Knowledge-is-proud-that-it-knows-so-much-wisdom-is-humble-that-it-knows-no. Accessed: December 2018.Search in Google Scholar
2. Coulehan J. “A gentle and humane temper”: humility in medicine. Perspect Biol Med 2011;54:206–16.10.1353/pbm.2011.0017Search in Google Scholar
3. Schulz K. Being wrong: adventures in the margin of error. New York: HarperCollins Publishers, 2011:167.Search in Google Scholar
4. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(Suppl 5):S2–23.10.1016/j.amjmed.2008.01.001Search in Google Scholar
5. Reason J, Manstead A, Stradling S, Baxter J, Campbell K. Errors and violations on the roads: a real distinction? Ergonomics 1990;33:1315–32.10.1080/00140139008925335Search in Google Scholar
6. Mele AR. Real self-deception. Behav Brain Sci 1997;20:91–102; discussion 103–36.10.1017/S0140525X97000034Search in Google Scholar
7. Croskerry P, Norman G. Overconfidence in clinical decision making. Am J Med 2008;121(Suppl 5):S24–9.10.1016/j.amjmed.2008.02.001Search in Google Scholar
8. Quote Fancy [Internet]. Available at: https://quotefancy.com/quote/72827/Socrates-What-screws-us-up-the-most-in-life-is-the-picture-in-our-head-of-what-it-s. Accessed: December 2018.Search in Google Scholar
9. Croskerry P. The feedback sanction. Acad Emerg Med 2000;7:1232–8.10.1111/j.1553-2712.2000.tb00468.xSearch in Google Scholar
10. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. J Am Med Assoc 2003;289:2849–56.10.1001/jama.289.21.2849Search in Google Scholar
11. Podbregar M, Voga G, Krivec B, Skale R, Pareznik R, Gabrscek L. Should we confirm our clinical diagnostic certainty with autopsy? Intens Care Med 2001;27:1750–5.10.1007/s00134-001-1129-xSearch in Google Scholar
12. Ioan B, Alexa T, Alexa I. Do we still need the autopsy? Clinical diagnosis versus autopsy diagnosis. Rom J Leg Med 2012;20:307–12.10.4323/rjlm.2012.307Search in Google Scholar
13. Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf 2005;31:106–13.10.1016/S1553-7250(05)31015-4Search in Google Scholar
14. Kopf AW, Mintzis M, Bart RS. Diagnostic accuracy in malignant melanoma. Arch Dermatol 1975;111:1291–2.10.1001/archderm.1975.01630220055001Search in Google Scholar
15. Dreiseitl S, Binder M. Do physicians value decision support? A look at the effect of decision support systems on physician opinion. Artif Intell Med 2005;33:25–30.10.1016/j.artmed.2004.07.007Search in Google Scholar PubMed
16. McGinnis KS, Lessin SR, Elder DE, Guerry D, Schuchter L, Ming M, et al. Pathology review of cases presenting to a multidisciplinary pigmented lesion clinic. Arch Dermatol 2002;138:617–21.10.1001/archderm.138.5.617Search in Google Scholar PubMed
17. Schoenherr JR, Waechter J, Millington SJ. Subjective awareness of ultrasound expertise development: individual experience as a determinant of overconfidence. Adv Health Sci Educ Theory Pract 2018;23:749–65.10.1007/s10459-018-9826-1Search in Google Scholar PubMed
18. Potchen EJ. Measuring observer performance in chest radiology: some experiences. J Am Coll Radiol 2006;3:423–32.10.1016/j.jacr.2006.02.020Search in Google Scholar PubMed
19. Sanchez C, Dunning D. Research: Learning a little about something makes us overconfident. Harvard Business Review. Available at: https://hbr.org/2018/03/research-learning-a-little-about-something-makes-us-overconfident. Accessed: May 2019.Search in Google Scholar
20. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med 2002;9:1184–204.10.1197/aemj.9.11.1184Search in Google Scholar
21. Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care 2006;15:159–64.10.1136/qshc.2005.016444Search in Google Scholar PubMed PubMed Central
22. Gorman PN, Helfand M. Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered. Med Decis Making 1995;15:113–9.10.1177/0272989X9501500203Search in Google Scholar PubMed
23. Rosenbloom ST, Geissbuhler AJ, Dupont WD, Giuse DA, Talbert DA, Tierney WM, et al. Effect of CPOE user interface design on user-initiated access to educational and patient information during clinical care. J Am Med Inform Assoc 2005;12:458–73.10.1197/jamia.M1627Search in Google Scholar PubMed PubMed Central
24. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635–45.10.1056/NEJMsa022615Search in Google Scholar PubMed
25. Berger AS. Arrogance among physicians. Acad Med 2002;77:145–7.10.1097/00001888-200202000-00010Search in Google Scholar PubMed
26. Coulehan J. Viewpoint: today’s professionalism: engaging the mind but not the heart. Acad Med 2005;80:892–8.10.1097/00001888-200510000-00004Search in Google Scholar PubMed
27. Coulehan J, Williams PC. Vanquishing virtue: the impact of medical education. Acad Med 2001;76:598–605.10.1097/00001888-200106000-00008Search in Google Scholar PubMed
28. Alfano M, Iurino K, Stey P, Robinson B, Christen M, Yu F, et al. Development and validation of a multi-dimensional measure of intellectual humility. PLoS One 2017;12:e0182950.10.1371/journal.pone.0182950Search in Google Scholar PubMed PubMed Central
29. Duff P. Teaching and assessing professionalism in medicine. Obstet Gynecol 2004;104:1362–6.10.1097/01.AOG.0000146287.86079.d9Search in Google Scholar PubMed
30. Klosterman C. But What if we’re wrong? Thinking about the present as if it were the past. New York: Penguin Books, 2017.Search in Google Scholar
31. Dunning D. Why incompetent people think they’re amazing. TED-Ed. Available at: ed.ted.com/lessons/why-incompetent-people-think-they-re-amazing-david-dunning. Accessed: October 2018.Search in Google Scholar
32. Heffernan M. Willful blindness: why we ignore the obvious at our peril. New York: Walker & Co, 2012.Search in Google Scholar
33. Ingelfinger FJ. Arrogance. N Engl J Med 1980;303:1507–11.10.1056/NEJM198012253032604Search in Google Scholar PubMed
34. Quote Fancy [Internet]. Available at: https://quotefancy.com/quote/929421/Voltaire-Doubt-is-not-a-pleasant-condition-but-certainty-is-absurd. Accessed: December 2018.Search in Google Scholar
35. Vedantam S. The hidden brain. New York: Spiegel & Grau, 2010.Search in Google Scholar
36. Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med 2011;86:307–13.10.1097/ACM.0b013e31820824cdSearch in Google Scholar PubMed
37. Gawande A. The Checklist manifesto: how to get things right. New York: Metropolitan Books, 2014.Search in Google Scholar
38. Fuller C, Cellura AP, Hibler BP, Burris K. Computer-assisted diagnosis of melanoma. Semin Cutan Med Surg 2016;35:25–30.10.12788/j.sder.2016.004Search in Google Scholar PubMed
39. Diprose W, Buist N. Artificial intelligence in medicine: humans need not apply? N Z Med J 2016;129:73–6.Search in Google Scholar
40. Thaler R, Sunstein C. Improving decisions about health, wealth and happiness. London: Penguin Books Ltd, 2009.Search in Google Scholar
41. Lowenstein EJ. Dermatology and its unique diagnostic heuristics. J Am Acad Dermatol 2018;78:1239–40.10.1016/j.jaad.2017.11.018Search in Google Scholar PubMed
42. Lowenstein EJ, Sidlow R. Cognitive and visual diagnostic errors in dermatology: Part 1. Br J Dermatol 2018;179:1263–9.10.1111/bjd.16932Search in Google Scholar PubMed
43. Lowenstein EJ, Sidlow R. Diagnostic heuristics in dermatology, Part 2: metacognition and other fixes. Br J Dermatol 2018;179:1270–6.10.1111/bjd.17127Search in Google Scholar PubMed
44. Gawande A. Cowboys and pit crews. New Yorker. Available at: https://www.newyorker.com/news/news-desk/cowboys-and-pit-crews. Accessed: November 2018.Search in Google Scholar
45. Townsend R, Bennis W. Up the organization. New York: John Wiley & Sons, 2007.Search in Google Scholar
©2020 Walter de Gruyter GmbH, Berlin/Boston
Articles in the same Issue
- Frontmatter
- Editorial
- Learning and teaching aren’t the same – the need for diagnosis curricula in graduate medical education
- Mini Review
- Controversies in diagnosis: contemporary debates in the diagnostic safety literature
- Opinion Paper
- Balancing confidence and humility in the diagnostic process
- Point/Counterpoints
- Roots of the total testing process
- Total testing process: roots and state-of-the-art
- Original Articles
- Embedding a longitudinal diagnostic reasoning curriculum in a residency program using a bolus/booster approach
- Structured case reviews for organizational learning about diagnostic vulnerabilities: initial experiences from two medical centers
- Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database
- Perspectives from the other side of the screen: how clinicians and radiologists communicate about diagnostic errors
- Routine coagulation testing in Vacutainer® Citrate Plus tubes filled at minimum or optimal volume
- Diagnostic accuracy of fine needle aspiration cytology of thyroid nodules
- Letter to the Editor
- The day God created man
- Case Reports
- Entamoeba histolytica liver abscess case: could stool PCR avoid it?
- A rare cause of subclinical hypothyroidism: macro-thyroid-stimulating hormone
Articles in the same Issue
- Frontmatter
- Editorial
- Learning and teaching aren’t the same – the need for diagnosis curricula in graduate medical education
- Mini Review
- Controversies in diagnosis: contemporary debates in the diagnostic safety literature
- Opinion Paper
- Balancing confidence and humility in the diagnostic process
- Point/Counterpoints
- Roots of the total testing process
- Total testing process: roots and state-of-the-art
- Original Articles
- Embedding a longitudinal diagnostic reasoning curriculum in a residency program using a bolus/booster approach
- Structured case reviews for organizational learning about diagnostic vulnerabilities: initial experiences from two medical centers
- Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database
- Perspectives from the other side of the screen: how clinicians and radiologists communicate about diagnostic errors
- Routine coagulation testing in Vacutainer® Citrate Plus tubes filled at minimum or optimal volume
- Diagnostic accuracy of fine needle aspiration cytology of thyroid nodules
- Letter to the Editor
- The day God created man
- Case Reports
- Entamoeba histolytica liver abscess case: could stool PCR avoid it?
- A rare cause of subclinical hypothyroidism: macro-thyroid-stimulating hormone
