On Dunning-Kruger, Surgical Self-Assessment, and Some Surgical Buzzwords to Watch out For
It's been well documented that people are generally poor judges of their own skills. Dunning and Kruger studied and published on this topic, creating the term Dunning-Kruger effect, which summed up, states that “poor performers are not in a position to recognize the shortcomings in their own performance”. Ehrlinger et all followed Dunning-Kruger in their paper “Why the Unskilled are Unaware: Further Explorations of (Absent) Self-insight Among the Incompetent," further coming to the conclusion that the relatively unskilled are unaware that they lack those skills. Other papers have shown that if you objectively split performers into quartiles, and then ask those quartiles where they believe there relative skills are, it comes out like this:
Top quartile of performers -> believes they are in the 2nd quartile
2nd quartile of performers -> believes they are 2nd or 3rd quartile
3rd quartile of performers -> believes they are in 1st or 2nd quartile
4th quartile of performers -> believes they are in the 1st or 2nd quartile
Effectively, the best performers think they are ok but could be better, while the worst performers believe they are at or near the top of performance. Effectively, they do not realize what they do not know.
I experienced this myself in my own medical education. As a high school and college student, I took education as an emergency medical technician, and then went on to work as a patient care tech in an emergency room all through college. I distinctly remember that at that time, I thought I knew a great deal about medicine. I was spending 40 hours a week in an ED watching doctors carefully, and indeed I was learning a lot about taking histories, interpreting X-rays, and so forth. But in reality, my knowledge in comparison to a physician was incredibly thin. But I remember thinking at that time that I pretty much had it figured out.
Once I went to med school, my mind was opened to the sheer vastness of knowledge that was out there to learn. I realized that what little knowledge I had achieved was actually nothing compared to what was out there. And the more I learned, the more I realized was out there to learn. Effectively, for every unit of knowledge I gained, I became aware of two more units of knowledge that I did not possess. So as a neophyte, I thought my knowledge was far greater than it actually was. The more experienced I became, the more I realized what I did not know, and thus my assessment of myself actually fell rather than rose. And each time I entered a new stage in education it repeated itself. I felt pretty smart graduating medical school, yet the first day of internship made me feel like an idiot. New experiences opened up new horizons to see what I still needed to learn.
And the same thing happened in my self assessment of surgical skills. I left residency feeling that I was a good surgeon. But really I wasn’t. I had basic understanding of how to do laparoscopy, but in reality I could be thwarted by any particular difficulty in anatomy. My knowledge of anatomy was quite poor compared to what it is today. If I operated on a patient with severely abnormal pathology like stage IV endometriosis at that time, I might have thought that the patient was ‘inoperable’ rather than seeing my difficulties as a sign of my own lacking skills, at that point in my surgical career. And furthermore, I was completely unaware that the surgery I was doing at that time was suboptimal for the patient. Not only was I not thoroughly removing the endometriosis, I was completely unaware that this was even the right thing to do. The very idea of that would have seemed so impossible that if a patient had told me she wanted that done, I probably would have thought she was foolish to believe that was even possible. Even though I had learned a lot and in some ways had become aware of certain knowledge deficiencies, in other areas Dunning Kruger was still in full effect.
Fortunately, over long period of experience and great training in fellowship, I was able to fill in those holes in my surgical education. I look back and realize that I was not actually very good at surgery when I left residency, and in truth I would not want my wife to be operated on the thirty year old version of me. While that version of me was actually pretty well trained for a recently graduated ob/gyn, compared to a true expert surgeon I was far more likely at that time to get into ‘misadventures” eg - to cause harm in surgery inadvertently.
A patient recently called me for a phone consult, and she told me some things that really made me think about the Dunning Kruger effect.
She had recently had a diagnostic laparoscopy that identified stage IV endometriosis, and her physician, a general OB/GYN, had made a plan to operate. And this is what she was told.
We are going to take our your uterus. We will try to do it laparoscopically, but there are a lot of adhesions and I will probably need to cut a cesarean type incision to finish the case. There was no discussion about removing deep infiltrating endometriosis.
I told the potential patient that while I have no idea what specifically are the experiences and talents of her surgeon, that the words spoken were not the words of an expert surgeon. On every point she was told, these were the buzzwords that revealed that the surgeon didn't have much experience in endometriosis surgery.
First, the physician said the primary point of surgery was to remove the uterus - This is not the primary goal of major endometriosis surgery. There are plenty of times we will remove a uterus in endometriosis surgery, but in the end if a person has stage IV endometriosis, the primary goal is to remove all the endometriosis from the pelvis. If one just removes the uterus, one will accomplish very little and the patient will still have substantial issues related to the endometriosis.
Second, the physician said effectively that If things get difficult they would convert to open surgery. This is the calling card of the mediocre laparoscopic surgeon. Laparoscopic or robotic surgery is the best way to operate in the pelvis, full stop. There are very few conditions that are more effective operated on open than laparoscopically. Open surgery puts the action 2 feet from your face, with bad lighting, and blood welling up in your field throughout the surgery. Laparoscopy puts everything magnified on a huge screen, with the ability to very precisely manipulate tissues and stop every bit of bleeding before it ever happens. In my mind, the more difficult a surgery is, the MORE I want to be operating laparoscopically, not the less. As a doctor who had achieved a very high level of skill in minimally invasive surgery, I can hardly imagine a situation where I would rather operate open. Truly the only situation would be if there were torrential bleeding that we needed to control quickly, and fortunately that basically never occurs (knock on wood). So basically if a surgeon tells you they might open if there area a lot of adhesions or things are “difficult," this is really code for “I am not a very good laparoscopic surgeon”. A doctor does not open because the surgery is difficult. They open because their laparoscopic surgery skills are not well developed and they need to operate open where they feel more comfortable with their technique.
Third, the physician was basically ignoring the primary issue causing the symptoms, which is the high grade endometriosis throughout the pelvis. If one hears this, one can be sure that the surgeon is not planning to, and is probably incapable of, removing the endometriosis. I don’t know of a single surgeon who has achieved the skills to excise a case of stage IV endometriosis who comes out of that process of training thinking that the disease should just be left there. But I do remember where I was when I was out of residency. I didn’t know that it would be useful to remove that disease, and if I had realized it, I wouldn’t have had the first idea of how to do it. But MOST IMPORTANTLY, at that point in my career, I would not have realized that there was a higher level of care that the patient could have been referred to.
I told this prospective patient that she should really see me or someone like me to do her surgery, and that if she did, the surgery would be substantively different from if it were done by her physician. We would thoroughly remove endometriosis. We would only do a hysterectomy if it were clearly necessary. And there was a nearly 0% chance that we would open to complete the surgery. Her likelihood of having a good outcome would be substantively higher.
But more importantly, why is her physician offering to do a surgery that they are not really very experienced with rather than just referring her to a higher level of care? Dunning-Kruger.
Even today in my practice, I’m sure the Dunning Kruger effect is still present to some extent. We are all affected by cognitive biases. But when one keeps an awareness of that bias, one can try to control for it. One of the best ways to keep control of this bias is to continue to read and learn, and to keep pushing one’s awareness of what knowledge is out there. Every paper you read teaches you something, but also shows you three other things that you don’t know. Every surgical video one watches teaches something, and may also demonstrate something that has not yet been mastered. And when I see a patient that I really think might get a better result with another surgeon, I tell them that. I have no interest in doing something badly that someone else could do better.