The Dunning-Kruger Effect, Or the Real Reason Why the Guys Trying to “Fix” Health Care Are Driving You Crazy

“The fool doth think he is wise, but the wise man knows himself to be a fool.”
– Willam Shakespeare

I learned about the Dunning-Kruger effect at a medical conference recently. It certainly seems to apply in medicine. So often, a novice thinks he or she has mastered a new skill or achieved full understanding of something complicated, but as time goes on, we all begin to see how little we actually know. Over time, we may regain some or most of our initial confidence, but never all of it. Experience brings at least a measure of humility.

Just the other day I finished a manuscript for an article in a Swedish medical journal with the statement that, 38 years after my medical school graduation, I’m starting to “get warm in my clothes”, as we say in Swedish.

I think the Dunning-Kruger effect applies not only to people who are in the beginning of a career in medicine, but also to people who learn about it for purposes of judging its quality or efficiency or of regulating or managing it from a governmental or administrative point of view.

I think many people outside medicine think “how hard can it be” and then proceed to imagine ways to change how trained medical professionals do their work.

But the Dunning-Kruger effect is also a particular problem in rural primary care. Newly trained physicians, PA’s and Nurse Practitioners are asked to work in relative professional isolation with full responsibility for sizeable patient populations. Unlike the hospital environment, primary care practices seldom have time earmarked for teaching and supervision, and there is little feedback given to such new providers. There is also very seldom collaboration and communication about specific patients or cases. We probably get more feedback from our specialist consultants than we do from the providers in our own clinics, because we are all busy with our own patients.

So, how does a new clinician avoid the newbie hubris Dunning and Kruger describe? Seek out potential mentors and ask them to be yours, start a case conference at your clinic, read the leading journals, NEJM, JAMA, BMJ, The Lancet and ones like them, and read about the history of medicine and the old masters.

And consider honestly how often a brand new driver should expect to instantly do better than the person who taught them, parent or driving instructor.

A medical license is in no way proof of mastery of the art of medicine, it is only a license to begin practicing, in a very literal sense.

Hans Duvefelt is a primary care physician in Maine. 

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2 replies »

  1. I loved your comments. Thank you. I find myself not agreeing, but not sure why. I will try, though, to explain.

    First, this curve is a curve of lack of knowing from beginning to end. In fact, I bet that many physicians at the tail end have confidence that is not warranted. A seemingly universal point about knowledge in medicine, playing chess, or any endeavor is knowing. Physicians should be aware that they are insufficiently trained in numeracy of science and knowing. Hence, they are confident to extreme as a marker of their lack of knowledge. The curve should be flat, should it not.

    Also, be careful advising to read those journals; I have been an associate editor, on boards, or reviewed for each of those. They are not a solution. They can present junk science and it is better to teach and encourage physicians to be skeptical and try to disprove everything they hear. They are hearing nonsense, often, and the better the scientist, the less the confidence curve, perhaps.

    Anyway, thanks again.

  2. As a Primary Physician, I have occasionally wondered what I would say if asked “What is it that you do?” Now retired, I was never really asked the question. But, here is my brief answer: “I manage the level of uncertainty underlying a person’s Unstable HEALTH by offering a Caring Relationship.” Putting aside a meaningful discussion for defining both HEALTH and a Caring Relationship, could the Dunning-Kruger Effect be optimized to improve our nation’s healthcare reform strategy? AND if so, the final question is: How could we persuade the Joint Commission on Accreditation of Hospitals to add a requirement for each hospital’s institutional governing body and C-Suite personnel to acquire meaningful experience regarding the level of uncertainty encountered by a Primary Physician in their Hospital’s community?
    I offer the following definition of an institution with a quotation from Nobel Prize winner, Elinor Ostrom:
    .An INSTITUTION may be defined as
    .”…the rules that humans use to organize all forms
    .of repetitive and structured interactions including within
    .families, neighborhoods, markets, firms, sports leagues, churches,
    .private associations, and governments, at all scales.
    .Individuals interacting within rule-structured situations
    .face choices regarding the actions and strategies they make take,
    .leading to consequences for themselves and for others.
    .The opportunities and constraints individuals face in any particular situation,
    .the information they obtain or are excluded from, and how they reason
    .about the situation are all affected by the rules or absence of rules
    .that structure a situation. If individuals who are crafting and
    .modifying the rules do not understand how a particular combination
    .if rules affects the actions and outcomes in a particular
    .ecologic or cultural environment, rule changes may produce
    .unexpected and, at times, DISASTROUS RESULTS.”
    ….[ capitals are my edit ]
    The cost and quality issues of our nation’s healthcare remain untouched by our current healthcare strategy. It will need re-formatted attention by all of the sectors of our nation’s civil life.

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