Medical Trainees and the Dunning–Kruger Effect: When They Don’t Know What They Don’t Know
Mariam Rahmani
Abstract
In 1999, psychologists David Dunning, PhD, and Justin Kruger, PhD, wrote a seminal article titled “Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments.”1 They described 4 experiments in which they asked college students to estimate their performance on tests involving humor, grammar, and logic. They were struck by the finding that students who performed poorly often grossly overestimated their performance. They also noticed that students who objectively performed well often subjectively underestimated their performance. This phenomenon is commonly known as the Dunning–Kruger Curve or the Dunning–Kruger Effect. It attempts to explain why people experience a blind spot when gauging their competence. Dunning and Kruger suggested thatFurther studies found that inaccurate self-assessments are explained both by lack of insight into their own performance in low-performing individuals and by lack of accurate perception of their peers' performances in high-performing individuals.1–3A graphic depiction of the Dunning–Kruger Effect is shown in the figure. At point A, inexperienced people often have a falsely elevated sense of confidence about their performance. With time and experience, they realize that they had been unaware of some intricate aspects of the job. This realization plunges their confidence (point B). As they continue to spend more time on the job, they acquire more experience and wisdom, ultimately gaining their earned confidence (point C). However, the confidence is never as high as it was at in the beginning. Paradoxically, by the time low-performing individuals achieve accuracy in their self-assessments, their performance has improved. In a nutshell, competence is required to identify areas of incompetency.Understanding the Dunning–Kruger Effect is important for leaders and trainees in graduate medical education because voluntary self-improvement requires recognizing the gaps in one's knowledge and skills as well as knowing how one is perceived by others. Although the Accreditation Council for Graduate Medical Education recommends that residents complete self-assessments periodically,4 studies have demonstrated that self-assessments by medical students, interns, and residents in general surgery, family medicine, and psychiatry are invalid measures of their objective performance.5–9Several medical studies support different portions of the Dunning–Kruger Curve. For example, 1 study found that junior physicians who were less competent tended to self-rate their efficacy higher than it was demonstrated (point A).10 Comparison of self-assessments and peer assessments of physicians in internal medicine, pediatrics, and psychiatry showed that those assessed in the lowest quartile by their colleagues tended to rate themselves 30 to 40 percentile ranks higher than their peers.11 A study showed that the lowest-performing physicians are the least likely to accept objective feedback on their performance.12 In another study, physicians did not perceive negative feedback as accurate or helpful and did not plan to use it to change their practice.13 Some physicians, after a period of reflection, were able to accept the negative feedback and use it for change. Others not only refused to accept the feedback but also questioned its validity and procedures.13Researchers have also found that more competent junior physicians tended to self-rate their efficacy lower than less competent ones (point B).10 This was especially true of women.14 It has also been shown that the more the time spent in learning and practicing a skill, the higher one's self-confidence about those skills (point C), regardless of objective improvement. For example, residents' competence across milestones increases with years of training.15 Improvement in competence and self-confidence with time has also been demonstrated in medical students and academic physician faculty.9,16–18The utility of recognizing the Dunning–Kruger Effect is helping junior physicians navigate their professional development, clinical expertise, and sense of self-confidence. It encourages physicians to be introspective, recognize their weaknesses, and beware of the limitations of self-confidence as a measure of clinical competency.The author suggests the following practical applications regarding the Dunning–Kruger Effect.