How Much Confidence is Too Much?

by Vidya Viswanathan

At the end of today’s session with Lewis Blackman’s mother Helen Haskell, I was really struck by her observation during the course of discussion: “Confidence kills.” In the documentary, Haskell also says of her son’s tragic death due to medical error, “He died because he was in the hospital.” As a rising fourth-year medical student, it stands in such stark contrast to the message I’ve gotten in my training, especially on rounds. Rounds often feel like a way to tie each patient up in a nice box with a fancy bow and meticulously ignore the true messiness that we are professionally obligated to address. Even as fresh, inexperienced students, we are taught to make a persuasive argument in our presentations and to always craft our presentation to fit our leading diagnosis. When we list differential diagnoses at the end of our presentations, the team often interrupts or rushes us to finish. On clerkships, while I saw the value in being definitive and persuasve if you felt true confidence in a diagnosis or it was an emergent situation, what didn’t make sense to me—and which I now view as harmful—was the push to do this as a trainee when in truth we often do not have the knowledge or experience to feel confident in tailoring a presentation toward one diagnosis. It felt misleading. Though in Lewis Blackman’s case we don’t have details from the residents of what they were thinking, I am curious if some of the residents did notice the warning signs but brushed them off in order to streamline their presentations and plan, so they wouldn’t have to contradict their leading diagnosis of post-op ileus. They would have to untie the fancy bow from the box and deal with what’s inside. 

So much of medical education and training feels like an evaluation, and when we are taught that the way to look more impressive and authoritative is to exude confidence even when we may not feel it (for legitimate reasons connected with our inexperience), I agree that it leads to increased risk of error. On the other hand, one thing I came away with after today’s lectures was the importance of having the confidence to speak up as a trainee when I see a medical error or patient detail being ignored. I was particularly struck by David’s story about the patient who was operated on the wrong side for inguinal hernia repair, and was lied to and told that he had two repairs that day. Many things pained me about that story: how vulnerable a patient is in that scenario; how the lie somehow feels even more unsettling than the original mistake; and how, it’s not something that is a thing of the past – I have seen surgeons lie to patients by omission in a way that is similar to that story. I have come away from today realizing that I need to work on building my confidence to not just observe these transgressions and emotionally react to them outside of the hospital, but also challenge them, even if it is just through the small but important action of safety reporting. As Tim noted, learning cannot happen without transparency; and I believe that a provider who is not transparent is not only unethical but unsafe.