Friday, September 16, 2016

A Tricky Question

This article was published in the December 2014 issue of Good Practice, the RACGP publication. I forgot I'd written it, so I'm posting it here now!

I’ve just learnt the most dangerous question in medicine. It’s “Are you a good doctor?”
I am sure, dear reader, that you are a good doctor. You know everything, and you know the things you need to learn. You can see through the twinkle in a drug rep’s eye faster than you can say Vioxx. You are all much better than average, and, even as you know enough statistics to be able to dismiss this as an impossibility, you also know that it is certainly not you who is below average.
Now that we are patting each other on the back in mutual admiration, here come some people to spoil the party. Let me introduce you to Dr Dunning and Dr Kruger
Dunning and Kruger won an Ignobel prize for their work, describing experiments showing that those who were the least competent in various tasks were also the most likely to rate themselves highly competent. They were also the most self-confident. There’s something about not being very good at something that makes you blind to the areas that you don’t know, or even realise that they are there. It’s a good job nothing like that could happen in medicine.
Except, sometimes, research evidence can be as disquieting as a mirror in a brightly lit room. In JAMA in 2006, Davis and colleagues did a systematic review comparing self-assessment with external observation. They tell us that we are not very good at assessing our own competence. Meanwhile, two years later In Medical Teacher, another systematic review by Colthard and colleagues also shows us that we are not that good at assessing our own learning needs.  In both situations it is the least skilled of us who are the worst at self-assessing, and who are the most confident.
And then there’s research that consistently shows we think we’re immune to drug rep marketing, no matter how often it’s shown that we’re not. This evidence is entirely consistent with other sociological and psychological research, which confirms that doctors are part of the human race, no matter how much we want to think our training makes us otherwise.
Apply Dunning and Kruger’s research to our profession, and you can see the danger in asking “Are you a good doctor?” It may be those very areas where we feel highly confident are just those areas we are worst at. It may well be that those of us who think they are expert at seeing through drug rep spin are those most susceptible. What if those of us who say they are good doctors are the ones we need to be most wary of?
Of course, you could dispute the evidence. All that stuff about education and drug reps doesn’t apply to you, or to Australia. But that is just what you would say, wouldn’t you, if you were subject to the Dunning-Kruger effect! To show how competent we are, we might have to admit uncertainty over our competence. In fact, in real life, I have discovered that the doctors I really admire all feel that at any moment, they will be tapped on the shoulder and outed as a fraud!
For any eager regulators out there wanting to put conditions on the registration of anyone admitting they think they are a good doctor, the solution is even more simple. As a profession, with specific knowledge and expertise, self-regulation often means peer review. We need, and should welcome, others around us to help us see our blind spots. Perhaps “Are you a good doctor?” is not such a dangerous question if our answer is “You’re asking the wrong person.”

Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of personality and social psychology. 1999 Dec;77(6):1121-1134.
Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA : the journal of the American Medical Association. 2006 Sep;296(9):1094-1102
Colthart I, Bagnall G, Evans A, Allbutt H, Haig A, Illing J, et al. The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Medical teacher. 2008 Jan;30(2):124-145.

Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003 Jul;290(2):252-255