By NIRAN AL-AGBA, MD and REBEKAH BERNARD, MD (4)
In 1995, McArthur Wheeler, a middle-aged, stocky man standing at five foot six and weighing 270 pounds, robbed two Pittsburgh banks in broad daylight. Wheeler wore no mask and did not attempt to disguise himself. When exiting both banks, he looked directly at the surveillance cameras and smiled.
Later that evening, police arrested Wheeler and showed him the surveillance footage. As he viewed himself on video, Wheeler appeared shocked, muttering, “but I wore the juice.” Wheeler later confessed that he had rubbed lemon juice on his skin. He had read that invisible ink was made from lemon juice and believed that applying the juice to his face would render him invisible.
The tale captured the interest of Cornell University psychologist David Dunning and his graduate student, Justin Kruger. The two theorized that some people were at risk for a faulty thinking pattern—the false assumption that their capabilities were far better than they really were. In their landmark study, Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments (1999), Dunning and Kruger developed the idea of illusory superiority, a false and undeserved inflated sense of self-confidence. They classified the condition as a form of cognitive bias or faulty thought process.
McArthur Wheeler was not stupid—just outrageously inept. His faulty thinking, or cognitive bias, was that he genuinely believed that lemon juice would make him invisible to surveillance cameras. Wheeler’s misunderstanding of the chemical properties of lemon juice allowed for his identification and capture. This concept of illusory superiority, now known as the “Dunning-Kruger effect,” describes a phenomenon in which people of lower ability overestimate their cognitive capability. Without adequate knowledge, some people are unable to recognize their own ineptitude, and without accurate self-awareness, those who are less capable cannot objectively evaluate their incompetence.
The Dunning-Kruger effect explains why people with the least amount of knowledge may insist that they are correct, instead of being confused, perplexed, or reflective about their erroneous ways. They genuinely believe the illusion of superiority. The effect is seen in the hubris of medical practitioners who have only trained for a fraction of the time as physicians, and yet insist that they are just as good, or that those extra years of training are unnecessary. This false self-confidence is dangerous, and the illusion of competence can lead to failed medical judgment with life-threatening consequences.
The flip side of Dunning-Kruger is true mastery of a subject and includes the humility found in those who are top experts in a field. However, even those who are masters in a field must be wary of the Dunning-Kruger effect, particularly in the sciences. Physicians are vulnerable to becoming stuck in outdated beliefs and practices that are no longer supported by the latest research. To avoid becoming “confident idiots,” as David Dunning terms it, we must constantly challenge our own knowledge and look for gaps in our understanding. Dunning recommends applying a sort-of Socratic Method to challenge our thinking, and that we seek advice by questioning and dialoguing with experts. Recognizing the concept of illusory superiority is vital to avoid ending up like the foolish bank robber. Without insight into our own self-assessment skills, we may act in an irrational, inept, or even stupid manner—like using lemon juice to make ourselves invisible. The key is to continually re-evaluate our competence to avoid being fooled by illusions of our superiority.
Examples of Dunning-Kruger
On Sunday, November 5, 2017, 10-year old Mya-Louise Perrin began vomiting. Two days later, she vomited again and had trouble standing up, so her parents brought her to Cromwell Primary Care Centre on the coast of England where nurse practitioner Ruth Loveday evaluated her. When she arrived at the clinic, the previously healthy child could barely walk down the hall. Despite the severity of her symptoms, this nurse practitioner diagnosed a urinary tract infection and sent the child home. That same night, Mya-Louise died of appendicitis.
At an inquest into Mya-Louise’s death, Loveday noted that at the time she was evaluating the child, she was quite sure that nothing was seriously wrong: “I felt confident my diagnosis was correct.” This is the fundamental element of Dunning-Kruger; nurse practitioner Loveday was overconfident in her knowledge. She truly didn’t know what she didn’t know. It never occurred to her to consider a more serious diagnosis. She didn’t have the experience to realize that simple urine infections don’t cause healthy children to struggle to walk.
Although there was no physician onsite when Loveday examined Mya-Louise, she acknowledged that she always had the opportunity to contact a doctor if she had any questions or concerns. However, she did not have the clinical acumen to realize that she needed to seek consultation with a physician. “With hindsight, I would seek GP advice,” she told the inquest.
Without extensive training, clinicians may experience gaps in their knowledge. Without experience, clinicians may not even realize that they need to ask for help – they don’t know what they don’t know. This lack of insight is particularly dangerous because it may impair a clinician’s ability to recognize a life-threatening problem.
“Physician Assistants and Medicine’s Tragic Dunning Kruger Trap” is excerpted from “Patients at Risk: The Rise of the Physician Assistant and the Nurse Practitioner in Healthcare.”
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Niran Al-Agba, MD is pediatrician practicing in Washington State. Follow her on Twitter at @Silverdalepeds. Rebekah Bernard, MD is a direct primary care physician practicing in Florida. Follow her on Twitter at @Rebekah_Bernard