I suffer from a metacognitive inability known as the Dunning-Kruger effect. I was working with a keen and knowledgeable intern who was suturing a wound in the posterior maxilla. Now, it was a rather difficult area but I gave the intern the room and time to practice this skill. During the 10 minute excursion to attempt to place one suture, a host of events occurred: ripping of the suture, turning the tuberosity into a pin-cushion, bending two needles, a loose gathering of the tissues and, finally, after the fourth suture pouch was opened and I was ready to stick the suction tip deep between my eyes, I finally took the new suture myself and bite-throw-throw-throw – I was done.
“That was so cool,” said the intern. “Not really,” was my retort, after having done this for the past 25 years to the point of mindlessness. My metacognitive disability was that I was unable to appreciate this novice intern’s challenges. It is a common frustration in educators but it is no different from any other task that requires practice and expert development. I assume that what is easy for me should be easy for others and that is a gross mistake and a poor assessment of my skills as an educator.
When I was a child I loved to cook with my mother. She would make gnocchi – little potato and flour dumplings. She would cut the dough into long strips and then into little one-inch lengths. The final dough was gently rolled and pressed across the tines of a fork to make a very pretty, textured pattern. My mother would flick one off every second and each one was perfect. I would smoosh, squish, contort, and destroy the dough and create abominations that would make my mother cringe and shake her head, recognizing that I would amount to nothing in life. She would laugh a little but persevered and now I can create a similar yet very poor duplication of her work. She too suffered from the DK effect.
The Dunning Kruger effect is a cognitive bias. During my studies in Surgical Education in the late 90s, Justin Kruger and David Dunning at Cornell University wrote in the 1999 Journal of Personality and Social Psychology a curious and often quoted work: most people cannot recognize just how incompetent they are: “Logic itself almost demands this lack of self-insight: for poor performers to recognize their ineptitude would require them to possess the very expertise they lack”. Their work was inspired by the story of a bank robber who covered his face with lemon juice in an attempt to be invisible to video cameras – just like invisible ink! The process by which we understand our own expertise and evaluate and regulate our knowledge, reasoning, and learning is called the study of metacognition. We think we are able to differentiate between what we know and do not know but indeed it seems that we fail to recognize our own ignorance. I thought I was making perfect gnocchi.
We tend to overestimate our abilities and performances over a wide range of skills, not just dentistry or surgery. The problem with our inability to detect our own ignorance is that it may be embarrassing or awkward or humorous. Jay Leno in a series of “Jaywalking” YouTube videos asks random people
basic history and science questions and the answers and display of ignorance is both hilarious and a little disturbing. Jimmy Kimmel in a similar vein sets up random people with a lie and rather than admit they do not know the subject will continue to lie to show they “know”. But this is nothing to laugh at–it can be dangerous. Dunning explains:
What’s curious is that, 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.
Oral and maxillofacial surgeons babysit the hospital emergency rooms of the country and manage “dental disasters”. Sadly, we can report volumes. There is a significant growth of complications that are occurring due to dentists going beyond their abilities. Indeed, hire a medical anesthetist to put patients to sleep and suddenly a super-specialist is created. A patient presented to the ED with a massive sublingual hematoma that needed a tracheotomy, neck drainage and ICU admission for a week. When I contacted the patient’s dentist, all my colleague was concerned about was that I did not touch the bone graft. He was emphatic as this was the first graft performed and this colleague did not want to ruin the ability to place an implant. No concern about the patient’s well-being. This dentist had just learned how to harvest bone from the chin during a weekend course “by a world expert” and now this dentist was an expert. They must have omitted the part of the pesky little arteries on the lingual aspect.
A misconception is that our perception of ignorance can be “cured” by education and that is simply not the case. Education oftentimes produces an illusory confidence with tragically horrible outcomes in our profession. More so, the rapid and rampant terabyte of educational opportunities on the internet or quick CE courses is making us even more “educated”. But are they making us competent? Are we jeopardizing the care of our patients? Is this good dentistry? Nowhere in medicine does one find a weekend CE course offered for GPs to perform coronary bypass grafts. It’s not even a dialogue. Why do we put ourselves in positions that compromise patients? Great blame goes to the marketing of implants and biomaterials that unfortunately drives and frightfully dictates our practices. Don’t even get me started on “Invisalign-creates-orthodontists-out-of-everyone” perversion.
Luckily, my week is filled with working with generalists that are outstanding practitioners of our art. It is actually these individuals that I worry about the most. I see on a daily basis the compassion, care, knowledge, and support that is offered to patients. These practitioners desire a cooperative culture and their motivation for self-improvement is evident in their work and is inspiring to me and my specialist colleagues. I believe that the few bad apples creating this problem are driven by a mixture of financial pressure or greed or are blind to their ignorance and the DK effect.
Even our great regulators, the Colleges, fall short in assessing our competencies. The farcical attempts to ensure practitioners are up to date and “educated” using online competency exams (I apologize for not responding to some of your emails on the oral surgery questions) highlights our ignorance even more (thanks to my endo friends for helping on those root canal things). But don’t get me wrong: it is a task they are mandated (albeit self-mandated) to do and they are trying their Dunning-Kruger best so they cannot be criticized or chastised. Unbeknownst to them, they are, to a certain extent, allowing and enabling the incompetency of some of our colleagues to grow and fester, creating a dark stain on this great profession.
How do we recognize and avoid compromising care based on our inabilities? The best advice may be to work within a group setting. Find peers to review cases. Find a study club but steer away from industry supported courses or those proposed by “experts” merely disguised as salespersons for their own benefit. We are inundated by CE courses promising the world. Support and use provincial and national organizations’ designed and audited courses or meetings. Create and nurture meaningful relationships that are educational with a range of specialists, find common ground – look at providing the “best dentistry” and avoid the cost per-hour-per-patient-per-staff divided by overhead-multiplied-by-lease-squared-by-the-mighty dollar approach that unfortunately the public perceives us by. Prior to difficult procedures I ask myself how I may be wrong. Am I doing the right thing? Recently, I was dealing with a medial orbital wall fracture. Maxillofacial surgeons are considered the experts but the fact remains that of the half dozen cases that present to the ED in a year, we treat very few of them – so the stress is on and I need someone to turn to. Is this the right diagnosis? Is this the correct approach? I call a friend. I ask a member of the audience. I get help.
Let us try to recognize and acknowledge our abilities and inabilities. Rushing to learn the newest technique so that it keeps patient dollars in our clinics is not good dentistry. I need to rely on my colleagues to better help my patients and I rely on co-educators to be the best teacher I can be. I cannot do it alone. We need to have a greater self-awareness and make sure that “best practices” has nothing to do with finances. Knowledge is a double edged sword, let’s learn to sharpen the correct edge and let us not make a parody of our expertise. Remember: primum non nocere. OH
References:
1. Kruger, Justin; Dunning, David (1999). “Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments”. Journal of Personality and Social Psychology 77 (6): 1121–34.
