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

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.