Dr Raj Rattan, Dental Director at Dental Protection, looks at why a practitioner’s confidence is misplaced without the competence to back it up.
It has been estimated that 27% of medical malpractice is the result of communication failure and handoff errors.
The prevalence of discontinuity in dentistry is significantly less because most care takes place in primary care and handoff incidents are, relatively speaking, very few. For this reason, we have to be cautious when interpreting medical statistics and applying the findings in dentistry. A careful analysis of clinical negligence cases arise not as a result of communication failure but competency issues.
The focus of risk management is usually the adverse outcome because it is not always possible to analyse competency related variables that may have contributed, sometimes significantly, to the clinical outcome. In endodontics for example, experience suggests some suboptimal outcomes can be attributed to lack of procedural knowledge and skill. In other words, the primary cause of failure is related to competency, with other factors contributing to the outcome.
Competence and competency are sometimes used synonymously, but there is a distinction. Competence is about the ability to do a defined task to a predetermined standard. Competencies describe the knowledge, skills, experience and attributes necessary for competence. Competence is conceptualised in terms of knowledge, abilities, skills and attitudes displayed in the context of clinical practice.
The stages of learning model is a useful psychological framework. It explains how people become more competent when learning a skill. There are four stages of competence often illustrated in a 2x2 matrix: see Figure 1. We can also access and assign risk scores as we move through the quadrants.
Level 1 – unconsciously unskilled
People do not appreciate how unskilled they are. To use a common phrase, they don’t know what they don’t know. There may be many reasons why a clinician may not be aware of their limitations – isolated practice, lack of peer review and ignoring colleague feedback are among them. These are therefore risk factors when it comes to potential complaints and claims. Litigation risk is, understandably, high because mistakes are made.
The individual must recognise their own incompetence – only then are they able to address their shortcomings. We also observe what is described as self-serving bias, where any failure is attributed to situational factors rather than to oneself. (The reader is referred to the literature on fundamental attribution error for a more detailed analysis.)
If the dentist has a growth mindset, the errors should motivate the clinician to do something about it.
The Dunning-Kruger effect, discussed later, applies.
Level 2 – consciously unskilled
The individual may not know how to do something, but they recognise the deficit. They are aware of the need to learn new skills, and this is therefore an intermediate stage of learning. Mistakes are made but the difference between level 1 and level 2 is that the individual is aware of the mistakes at level 2.
Level 3 – consciously skilled
At level 3, the individual is now aware that they have acquired the appropriate skills. Risk is reduced because the individual is often aware of their limitations. Confidence grows – justifiably, because it is built on the foundations of competence.
Level 4 – unconsciously skilled
Work is carried out effortlessly. Clinical procedures are second nature and performance has been described as intuitive. This concept of intuition is often cited and reported but remains nebulous. It is almost like a sixth sense when it comes to managing risk.
If you happen to be an observer, it is a joy to watch the unconsciously skilled at work. Risk is low, but the unconsciously skilled may be distracted so it is important to maintain concentration. The use of checklists, for example, is still advocated because it focuses the mind at key stages of a given procedure.
Competences are acquired mainly through experience – our own experience and that of others who share theirs. This vicarious experience involves watching others at work and observing outcomes of interventions as well as the consequences of behaviours in general. The value of this approach should not be underestimated; when observers watch people like themselves, it strengthens their belief that they too can be like them.
This is a type of cognitive bias that results in an overestimation of capability. It is named after David Dunning and Justin Kruger, the two social psychologists from Cornell University who first described it in their seminal paper published in 1999.
It relates to an overestimation of ability. People who perform poorly are unable to judge their own performance accurately – this has been shown to be the case in a wide range of tasks. People who performed poorly frequently overestimated their performance and those who performed well often subjectively underestimated their performance compared to others.
A graphic representation is shown in Figure 2.
At point A, the inexperienced have a false sense of confidence about their performance. After a little time and more experience, it dawns on them that they had been unaware of some aspects of their work and their confidence plunges to despair at point B. With more experience over time, their confidence increases again on what is described as the ‘slope of enlightenment’ till they reach point C.
It is worth reflecting on the words of David Dunning in an article he wrote back in 2017: “In many cases, incompetence does not leave people disoriented, perplexed or cautious. Instead, the incompetent are often blessed with an inappropriate confidence, buoyed by something that feels to them like knowledge.”
The false sense of confidence at the outset may be exaggerated even more if training programmes encourage participants to adopt new techniques and treatment modalities without adequate training. The Dunning-Kruger effect prevents people from overcoming their weaknesses (knowledge or skills) because one of the prerequisites for self-regulated learning is awareness of one’s own deficit.
It is something that we are aware of from a risk management point of view and is a concern going forward.
Confidence in clinical practice is the belief that one has the ability to deal with situations and clinical challenges effectively. Society at large places a premium on being confident; a confident demeanour is also considered attractive and persuasive. We know from research that self-confidence is an attribute that patients value.
It is not surprising then that people invest time and money to try and learn how to appear more confident. There is no shortage of courses and self-help books to choose from. But is this the best way to build confidence? Are we missing the point? If someone is able to feign confidence without the competence to back it up, then confidence is illusory. But confidence is so highly prized that many people would rather pretend to be skilled than risk looking inadequate in front of colleagues and patients. The idea that it is acceptable to ‘fake it till you make it’ is troubling to say the least and a recipe for risk.
Low confidence is not always a bad thing if it is the result of an accurate self-assessment of competence. Awareness of this bias will encourage inexperienced dentists to be introspective and recognise their weaknesses. Educators should not rely on measures of self-confidence as a measure of competency.
Tomas Chamorro-Premuzic is Professor of Business Psychology at both University College London and Columbia University. In his book Confidence: How Much You Really Need and How to Get It, he emphasises the importance of competence over confidence. He concludes that the reason exceptional achievers have confidence is that they are also exceptionally competent.
Contrary to popular belief, he suggests the chances of success are better when you have low confidence. It lessens the chances of coming across as arrogant. Lower self-confidence reduces the chances of coming across as arrogant and Chamorro-Premuzic writes that “the consequences of hubris are now beyond debate”.
We should beware the illusion of confidence. It is a trap unless it is borne of competence. It is about becoming better rather than simply feeling good.
Dunning D, “We are all confident idiots”, Pacific Standard 14 June 2017