October 23, 2023
by Steven Willing, MD
“A lack of humility is the source of every defect and failure.”
I’ve seen it happen. If you have been in healthcare for any length of time, you probably have too.
Sometimes, our physician colleagues injure those who entrust us with the care of their minds and bodies, and sometimes, it truly is their fault.
In a feature article—one that rang all too true with my own experience—The New York Times ran a reported last summer on the cottage industry of catheter-based revascularization. According to The Times, a combination of industry funding and high reimbursement created a booming industry built on procedures of dubious clinical efficacy. The article focused on the practice of Dr. Jihad Mustapha, reporting that in a mere four years, 45 people had lost their limbs after treatment at his clinics.
Some medical procedures require extreme caution and skill to avert devastating complications. The slightest slip of a hand, the briefest lapse in concentration, errors of split-second decisions under maximum stress—there are almost unlimited ways to cause inadvertent injury, which could be disabling or fatal. Experience and skill matter. Immensely. That’s why training programs last years. In my area of neuroradiology, I knew of instances where untrained physicians set out to attempt carotid catheterization, leading to preventable strokes and even death. Why would they do it, when experienced and competent operators were available?
What The Times did not address is the mindset of the physicians engaged in such practices. More often than not, it’s framed as a simple matter of greed. “Follow the money,” as the cliché goes. However, it would be pretty exceptional for anyone to endanger the life or health of another purely for financial gain. That’s not just greed. It’s psychopathy.
There’s more to the picture. Despite an unacceptably high complication rate, such physicians invariably believe they are competent, perhaps even exceptional.
What are you good at, and just how good are you? How do you know?
As we pass through life, we form opinions regarding our personal competence in numerous domains: our intelligence, our professional expertise, our athletic prowess or our artistic and creative talents, to name but a few. Overconfidence can lead to failure, presents an impediment to growth and can harm those who depend upon or trust us.
The Lake Wobegon Effect
A series of studies over past decades demonstrated that we are prone to overestimate our abilities in leadership, athletic prowess, driving, general intelligence and other areas of expertise.
This tendency, called the better-than-average effect (BTAE), is also known as the “Lake Wobegon Effect,” after the fictitious Minnesotan town where “all the women are strong, all the men are good looking and all the children are above average.” In 2020, a group of psychologists published a comprehensive review of the better-than-average effect. Across all studies, the BTAE was robust, reproducible and highly significant.
College professors are a particularly confident lot, with 94 percent rating themselves above average in how well they do their jobs. (Remember that next time they remind us how superior they are to ordinary folk. They also think they’re better than each other.)
We physicians also tend to be pretty sure of ourselves. When I was 24, I achieved an early life dream of getting a pilot’s license. Not long afterward, though, reality set in. It was a fun hobby, but it was expensive and not that practical. Worse, I started hearing from multiple sources that physicians made terrible pilots and were much more likely to die in accidents. As it turns out, that’s been documented. Most general aviation accidents are due to pilot error, and lack of caution is a major contributing factor. Pilots can be too confident, with sometimes fatal consequences.
Incompetent and Unaware?
In a series of tests on college students (over humor, grammar and logic), Justin Kruger and David Dunning found that those who performed in the bottom quartile dramatically overestimated their own ability and performance. Conversely, the highest-scoring students rated themselves lower than they deserved—until they learned just how badly their peers really did. Not only did the least competent students overestimate their competence, but they failed to recognize competence in others. Thus, they lacked any frame of reference to form an accurate self-appraisal. Finally, and somewhat ironically, the only way they were able to recognize their incompetence was in hindsight, after they received training to raise their competence. In honor of their work, Kruger and Dunning were awarded one of the 2000 “Ig Nobel” awards, disbursed annually to 10 winning achievements that “first make people laugh, and then make them think.”
The Egoistic Immune System
Now, one might naïvely think that ineptitude should be hard to overlook. Incompetence leads to failure, and aren’t we all going to recognize sooner or later that our batting average isn’t quite up there with the rest of the team? That’s how it should work, but pride doesn’t surrender so easily. Our egoistic immune system kicks in. The face-saving way is to blame failure on bad luck or external circumstances. For many, the least likely outcome is to reasonably conclude, “Well, I must not be that good at it.” Those healthcare professionals experiencing bad outcomes can console themselves, thinking, “Complications do happen, even to the best of us.”
There is yet another defense used by our egoistic immune system when our performance isn’t up to expectation: the practice of “self-handicapping.” We all do it sometimes. Before taking that exam, we tell ourselves and others, “Well, I had to work late last evening, didn’t have enough time to study and then lay awake all night worrying about those poor drowning polar bears.” Before taking that tee shot, “You know, my back’s really been bothering me, and I haven’t had a chance to break in this new driver.”
When our performance is on the line, we can either feign incompetence or attempt to lower expectations. It’s a win-win situation for the ego. If I do poorly, the outcome was predicted. If I succeed, it’s a story of triumph over adversity. What a deal! No wonder we use it so much. The catch is that nobody else much buys it. Do you buy their excuses?
A Lesson from Scripture
Most are familiar with the biblical account of Samson. A mighty warrior, he was endowed by God with preternatural strength and became the scourge of the Philistines. His enemies sent a “honey trap” in the person of Delilah, who conspired to pry from Samson the secret of his strength. Samson repeatedly lied, and three times he ambushed the would-be ambushers. Eventually, he succumbed to her prying and was captured. The shaving of his head rendered him powerless.
Why did Samson betray his secret in the end? He must have deduced that Delilah was up to no good. No one is that naïve. Scripture explicitly states he succumbed to the nagging of Delilah, but it seems improbable Samson would have given in if he genuinely thought he’d be captured or killed.
We already know Samson was overconfident; after all, he imagined he’d killed a thousand Philistines without any divine assistance. Delilah was transparent enough. What you saw was what you got.
His liaison with Delilah was like playing footsie with rattlesnakes or wearing a MAGA hat in Portland, Oregon. Based on his track record, when he finally divulged his secret to Delilah, he probably felt pretty confident. He always triumphed without giving much credit to The True Source of his strength. Maybe he no longer believed his long hair had that much to do with his power. He was a winner!
Of course, his confidence was unwarranted because, all along, the power was in God, not Samson. Just. Like. Ours.
One Size Doesn’t Fit All
None of this should be interpreted as applicable to all comers. Some of us may actually be on the opposite side of the fence. We may feel incompetent, even when we are at least capable and maybe even above average. In the Dunning-Kruger effect, this was common in the highest performers.
In some cases, a low self-appraisal engenders what is known as “the imposter syndrome.” This is a phenomenon where someone feels inadequate, perhaps even fraudulent, despite being well-qualified. The precise opposite of overconfidence, the imposter syndrome is curiously more common among physicians than other American workers.
Feeling a bit underqualified is not necessarily a bad thing if it keeps us humble and driven toward lifelong learning, but more severe cases of imposter syndrome can lead to professional dissatisfaction and burnout.
One side of pride is self-exaltation, overestimating our place in the universe. The other side is overconfidence, thinking too highly of our abilities, thoughts or moral standing. For any given individual, this may be true in a few areas or many. Preserving that self-image sometimes demands that we overrate our competence in the areas that matter most. Thus, self-exaltation requires overconfidence, and overconfidence sustains self-exaltation. The two feed upon one another with a singular purpose: to see ourselves as we wish to be—rather than as we truly are.
Overconfidence in ability is a dangerous thing. In the hands of healthcare professionals, engineers or pilots—some might add hairdressers—it can lead to disaster. It was fatal to Samson. Where less is at stake, it may still result in conflict, squabbling, divisiveness or mediocrity.
Pride deceives us in many ways, and one way is to overestimate our competence and skill. In high-risk situations, the consequences can be disastrous. Pride kills. Humility can be lifesaving.
“For I say, through the grace given to me, to everyone who is among you, not to think of himself more highly than he ought to think, but to think soberly, as God has dealt to each one a measure of faith.”
—Romans 12:3, NKJV
Adapted from Superbia: the perils of pride. The power of humility. by Steven J. Willing, MD