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Ideas and Opinions |16 October 2018

A Student Reflection on Doctoring With Confidence: Mind the Gap Free

Nicole Treadway, BA

Nicole Treadway, BA
Emory University School of Medicine, Atlanta, Georgia (N.T.)

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
This article was published at Annals.org on 11 September 2018.
  • Emory University School of Medicine, Atlanta, Georgia (N.T.)

    Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0865.

    Corresponding Author: Nicole J. Treadway, BA, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30307; e-mail, nicole.treadway@emory.edu.

    Author Contributions: Conception and design: N. Treadway.

    Drafting of the article: N. Treadway.

    Critical revision of the article for important intellectual content: N. Treadway.

    Final approval of the article: N. Treadway.

    Administrative, technical, or logistic support: N. Treadway.

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On a recent Friday evening, I met several female classmates for dinner—an event that has become more precious, if less frequent, over the course of our third-year clerkships. Although our medical school assigns each of us to a small group for discussion of professionalism and debriefing of clinical experiences, there is an intimacy in our group of women that enables honesty and vulnerability. In the assigned groups, we are eager to share our success stories, compare notes on the procedures we have witnessed, or describe particularly meaningful interactions. In our chosen group, we share our perceived failures, discuss the criticisms we have received, and identify our fears.
On this evening, one woman began by expressing her disappointment about feedback she received during an internal medicine rotation. After being complimented on a thorough patient presentation on teaching rounds, she was told by her attending physician that she “needed to present with more confidence.” She also detailed another occasion when a student was praised for speaking assertively even though her concluding diagnosis was clearly incorrect. Within minutes, all 4 of us remembered moments when we had received feedback like this, often after the presentation of a patient care plan on wards, and once as a general statement in a written clinical evaluation. Together, we struggled to understand. What did these comments mean, and why did being told to act more confidently make us feel uncomfortable?
In the ensuing days, an informal survey of our classmates suggested that female colleagues were being told to act confidently more frequently than our male counterparts. If real, this pattern should not be surprising. A discrepancy in confidence along gender lines—known as the “confidence gap”—has been documented in the literature among academic faculty (1), business professionals (2), and medical learners (3). In the business and academic arenas, studies have found that women more frequently underestimate their performance (4). In medicine, female physicians fail to negotiate salaries that are comparable to those of their male colleagues (5).
The solution? Encourage women to “lean in,” “speak up,” and “fake it till you make it.” I see women being urged to take credit more often, apply for opportunities more regularly, and negotiate their contracts more aggressively. Sometimes, women are advised to adopt different ways of communicating. In September 2017, the Massachusetts Medical Society advertised a talk on “confident communication” for its Women in Medicine series, where attendees would learn to build “assertive communication skills” deemed “essential for impactful interactions and social influence” (6).
The need for women to change their behavior, however, is less clear in patient care settings. A 2017 study suggested that elderly hospitalized patients treated by female hospitalists were less likely to die or be readmitted 30 days after admission than were patients of male hospitalists (7). Although the adjusted risk differences between genders were modest, the scope of practice was limited, and residual confounding could explain the findings, the results were intriguing. The authors hypothesized that greater adherence to clinical guidelines (8) and more patient-centered communication (5, 9) by female physicians compared with male physicians could play a role. We must consider that female physicians may be doing something, or several things, that is different and effective.
In response to the suggestion to act more confidently, my classmates and I reviewed our actions to determine which behaviors merited the comments. When formulating our care plans, we remembered reexamining guidelines, triple-checking calculations and orders, and seeking reassurance from our residents that we were doing things correctly. When answering questions about our patients' pathology or treatment, we sometimes hesitated or used modifiers like “I think” or “but I'm not sure.” Expressing our uncertainty had felt preferable to feigning sureness. Now we wondered: Were we not supposed to feel unsure, or were we not supposed to express it?
Given the unavoidable uncertainties present in the learning and practice of medicine, I wonder whether speaking with confidence should be a highly prioritized skill. Proponents of a “partner in health” model of care embrace a clinical relationship with patients that is characterized by nuanced discussion of medical uncertainty (10). In accordance with this approach, more male and female trainees may benefit from greater guidance on how to deal with not knowing the answer when interacting with colleagues and patients.
Many may agree that this makes sense in a clinical context, but educators may believe that a recommendation to adopt greater confidence in a teaching setting is an appropriate, constructive criticism meant to cultivate leadership skills when surrounded by colleagues. Seasoned clinician-educators likely use different styles of communication with students on teaching rounds versus with patients. It may be worth remembering, however, that communication styles with colleagues and patients are not learned independently. Students likely develop broader communication habits that fit in the culture modeled, including preference for independent versus cooperative problem solving and tolerance of uncertainty. Therefore, encouraging students to speak assertively, even during teaching rounds, may neglect to reinforce honest and collaborative communication in teaching and patient care settings.
Moreover, if students do not utilize their moments of uncertainty to receive clarification or ask follow-up questions for fear of betraying a lack of confidence, they may not learn as effectively or act as precisely. The questioning and reassurance seeking that can seem problematic in female trainees may contribute to a culture of safe, collaborative doctoring. Thus, advising female trainees to be more confident when offering their thoughts and care plans could undermine an advantageous, cautious approach to patient care.
Ultimately, closing the confidence gap in medicine will require female and male physicians to ask for more—more training on how to adopt a collaborative approach to patient care characterized by greater tolerance of uncertainty, more appreciation of a cautious attitude paired with diligent study, and more recognition of women's communicative strengths and equal ability to achieve beneficial health outcomes (5). To aid this effort, our attending physicians may want to consider whether their confident students could benefit from opportunities to acknowledge and discuss their uncertainty.

References

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  6. Massachusetts Medical Society. Event Profile: Women's Leadership Forum: Confident Communication: Achieving Socially Intelligent Leadership. 2017. Accessed at https://portal.massmed.org/eweb/DynamicPage.aspx?webcode=EventInfo&reg_evt_key=AE31DB18-F59E-45AA-AA11-62A9C7B06EC5&RegPath=EventRegFees on 19 June 2018.
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4 Comments

Richard L. Kravitz

Division of General Medicine, UC Davis

September 10, 2018

Gender and Confidence

In her commentary, Ms. Treadway raises two fascinating and important questions: 1) Are we encouraging over-confidence; and 2) Does gender matter? The answer to the first question is probably yes (with a caveat), but the answer to the second question is less clear than the essay implies. In the cited article by Blanch et al., the mean difference in confidence between men and women is about one-third of a standard deviation, implying substantial overlap between the sexes. Overconfidence (and underconfidence) can be a problem for both men and women. Returning to the caveat, there may be pedagogic advantages associated with a crisp, confident presentation, provided time is allocated for correction of mis-impressions or errors. From the educator’s perspective, a hesitating style is more difficult to follow. Studies are needed to determine how educators can support learners in developing greater presentational fluency without suppressing discussion of uncertainty.

John E. Coda

Penn State College of Medicine

September 15, 2018

Confidence and Competence: A Broader Issue

Early in my third year of medical school, as part of a primary care clerkship, I took part in a series of standardized patient encounters meant to evaluate our ability as effective communicators. Following one encounter, I received feedback from the patient actor that I had voiced uncertainty too often when challenged by his character, beginning my responses with modifiers such as, “I think.” Puzzled, I asked the actor how I could have better responded, given my uncertainty regarding the patient’s precise diagnosis and prognosis. The actor responded that, “the patient should not have doubt in the doctor” and that I would benefit from, “expressing more confidence, even if uncertain.”

Throughout my clinical rotations, I routinely received similar feedback from my residents and attendings, most often in the context of patient presentations. I was told to speak with more confidence and to not express doubt regarding my proposed plan, even when I was unsure--that it was more important to be confident than correct.

As a male student, I had not previously considered my limited experiences as correlated with gender, and I read with great interest Treadway’s reflection on the “confidence gap” and her experiences of this phenomenon in her clinical training (1). A student’s portrayal of confidence may have implications for their performance within a clerkship. The effect of various noncognitive variables, including communication variables, on clerkship performance has been previously studied by Lee and colleagues (2). They found that being less assertive and more reticent were associated with lower clerkship grades. Female students were less assertive and more reticent than males, although with significant overlap, potentially supporting Treadway’s argument for the existence of a “confidence gap” in the clerkship setting.

Notably, racial differences in these same communication variables were also present, with underrepresented minorities showing greater reticence and less assertiveness than white students. Underrepresented minorities had lower grades across all clerkships, a finding that could be partially explained by their differences in communication. However, as the authors point out, this was a cross-sectional study and causation should not be assumed.

To what degree should we value confidence in the medical student, and to what degree does a student’s portrayal of lack-of-confidence impact their performance in clerkships? These are questions as applicable to individuals across all demographic subgroups. Nevertheless, evidence for differential displays of confidence between various subgroups including gender and race are concerning and warrant further study.

1. Treadway N. A Student Reflection on Doctoring With Confidence: Mind the Gap. Ann Intern Med. [Epub ahead of print ] doi: 10.7326/M18-0865

2. Lee KB, Vaishnavi SN, Lau SK, Andriole DA, Jeffe DB. “Making the grade:” Noncognitive predictors of medical students’ clinical clerkship grades. J Natl Med Assoc. 2007;99:1138–1150. [PMID: 17987918]

Juan N. Lessing MD FACP, Mary E. Lacy MD FACP

University of Colorado School of Medicine, University of New Mexico School of Medicine

October 30, 2018

Commitment Not Confidence

TO THE EDITOR:
Ms. Treadway’s perspective piece (A Student Reflection on Doctoring with Confidence: Mind the Gap) (1) opened our eyes to the possibility that we are unwittingly treating learners differently based on gender. We also agree that it is important to discuss our own uncertainty, amongst ourselves as much as with our patients. Further, as medical educators who have no doubt told learners to present with confidence countless times, our attention was drawn to how this feedback might be being perceived/interpreted. The burden of clarity in setting expectations falls upon us as educators, and as Ms. Treadway makes clear, we have been missing the mark.

A recent example comes to mind where an intern in reply to “be confident” said, “So, you want me to speak confidently even if I have no idea what I’m doing?”

Educational literature tells us that the greatest learning takes place when it is effortful and exposes us to the concepts we do not recognize that we don’t know (2). Coming to your own decision and reasoning (taking a stand, or the proverbial “putting your money down”), even—and we would argue, especially—if wrong (so long as corrected with explanation why) is where the greatest learning takes place (3).

The aforementioned intern’s comment, within the context of Treadway’s writing, made us realize that we should not be using the word confidence in this setting. Instead, we should set an expectation for our learners to make a commitment to their plans, rather than to just present with confidence. Establishing this as a consistent expectation, rather than providing the individualized and general feedback “be more confident” after the fact, would be far more clear, effective, and equitable. When setting expectations with future learners, we aim to say: “I want you to commit to a diagnostic and management plan. I promise I won’t let you enact a plan that I know to be wrong or harmful to our patients. But to help you grow, you need to come to your own decision about diagnostic possibilities and next steps....You don’t need to be right, but you do need to have a well-formed opinion.” We also believe, consistent with Ms. Treadway’s discussion about the value of discussing uncertainty, that a learner’s commitment to a plan should be the beginning of the conversation, rather than the end.

The clarity of our language matters. We, and perhaps others, have used the wrong terminology when telling learners to “speak with confidence.” Given the opportunity, we would welcome Ms. Treadway’s thoughts on our suggested approach, and ask how she believes we can best achieve our mutual goals of gender equity and encouragement of discussions about uncertainty, all the while requiring commitment?

Disclosures: None

References
1. Treadway N. A Student Reflection on Doctoring With Confidence: Mind the Gap. Ann Intern Med. 2018 Oct 16;169(8):564-565. doi: 10.7326/M18-0865. Epub 2018 Sep 11. [PMID: 30208402] doi: 10.7326/M18-0865
2. Brown, Peter C. Make It Stick : the Science of Successful Learning. Cambridge, Massachusetts: The Belknap Press of Harvard University Press, 2014.
3. Lemov, Doug. Teach Like a Champion: 49 Techniques That Put Students on the Path to College. San Francisco, California: Jossey-Bass, 2010.

Nicole Treadway, BA

Emory University

January 14, 2019

What we talk about when we talk about confidence

I’m deeply appreciative of the thoughtful and nuanced comments provided by Drs. Kravitz, Coda, and Lessing in response to my recent publication(1). It’s incredibly gratifying to see the piece stimulate meaningful discourse. First, in response to Dr. Kravitz and Dr. Coda, I want to readily acknowledge that there is, of course, overlap in overconfident and under-confident approaches shared by men and women, and that these styles may be associated with other dimensions not explored in my original article; Dr. Coda’s recommended article by Lee et al (2) brought important attention to racial subgroups that may also be impacted by a continued preference for an assertive style.

Letters from other readers have also raised issues worth examining; an additional problem with “confident” language was highlighted when one reader wrote, “why should confidence and an admission of uncertainty be mutually exclusive?” This led me to reflect on the way the word’s multiple meanings- expression of surety and comfortable self-awareness - are conflated. Using the second definition, it’s unsurprising that experienced physicians see no conflict in “confidently” telling a patient “I don’t know”.

A few readers relying upon the first definition have insisted that confidence is a sign of preparedness. In my experience, however, the comment was offered to peers with unsurpassed motivation and discipline A potentially more complicated response comes from those who argue that their patients prefer an assertive physician. At a time when patient satisfaction ratings play an unprecedented role in physician reputation and compensation, this is not a trivial concern. However, if a less paternalistic, more collaborative approach is truly associated with better health outcomes, patient preferences should not prevent us from updating our practice.

Many, like Dr. Lessing, have explained that their comments reflect a desire for trainees to commit to a decision regarding diagnosis and management. I too see the value in encouraging learners to synthesize data and present their own conclusions. I’d hope, however, that the learning benefits of “putting your money down” would not be diminished if learners were encouraged to show how they arrived at (or stumbled onto) their decision. I strongly support setting more specific expectations for learners within a supportive environment that includes tolerance for trainees with informed, if still uncertain, opinions.

1. Treadway N. A Student Reflection on Doctoring With Confidence: Mind the Gap. Ann Intern Med. 2018 Oct 16;169(8):564–5.
2. Lee KB, Vaishnavi SN, Lau SKM, Andriole DA, Jeffe DB. “Making the grade:” noncognitive predictors of medical students’ clinical clerkship grades. J Natl Med Assoc. 2007 Oct;99(10):1138–50.

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Treadway N. A Student Reflection on Doctoring With Confidence: Mind the Gap. Ann Intern Med. 2018;169:564–565. [Epub ahead of print 11 September 2018]. doi: https://doi.org/10.7326/M18-0865

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Published: Ann Intern Med. 2018;169(8):564-565.

DOI: 10.7326/M18-0865

Published at www.annals.org on 11 September 2018

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2018 American College of Physicians
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