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Clinicians’ overconfidence: Lessons from a misdiagnosis

“He who knows best knows how little he knows.”

Ball player’s self declaration to be “the King”, self-help book with chapter titled “Kill the critic inside” ,
parents posting pictures of their toddlers on social networks wearing bibs saying “Ridiculously Good
Looking”, are just a few instances of increasingly visible culture of self-admiration and self-promotion.
With Good intentions our culture promotes self-admiration with the belief that it creates a positive
attitude and increased self esteem. However in the haste to raise children’s opinion of themselves we may
have opened the door to escalation in overconfidence to levels alarmingly close to narcissism which
results in a distorted concept of reality and ability. Later in life individuals carry these traits into their
professional life where in certain occupations mistakes are especially costly. In fact the connection
between inflated confidence and key participants in financial, military and political failures are well
documented. In medicine, a study published in the June 2006 issue of Journal of American College of
Radiology examined practitioners’ confidence in diagnosis using radiographs. Dr. Potchen’s study
showed that while the ability to accurately diagnose varied, the subjects’ confidence in the correctness of
their diagnosis remained high. More definite evidence of clinicians’ overconfidence can be found in a
study published in November 2001 issue of Journal of Intensive care medicine in which autopsies were
used as gold standard of diagnosis. Dr. Podbregar found that physicians reporting “complete certainty” of
the diagnosis ante-mortem were mistaken 40% of the time.

The purpose of this article is neither to discount the importance of practitioners’ trust in their abilities nor
to clinically diagnose dental students with narcissism. The article simply aims to warn students about the
rise in overconfidence in professional circles and introduce them to its ramifications so by practicing self-
awareness they avoid making costly mistakes. The article was prompted by an encounter with two
physicians, whose overconfidence in what turned out to be limited knowledge prevented them from
exploring alternative possibilities to their initial diagnosis. The tunnel vision created by their
misconception of extent of their clinical understanding lead to a three month delay in final diagnosis of an
aggressive lymphoma. The physicians approach to this case parallels with two traits exhibited in
Narcissist personalities: overconfidence and self-justification.

In the age of Evidence based dentistry, dentists need to be aware of the latest research and guidelines
available to be considered a professional with proficient expertise. Overconfidence creates lack of
motivation to proactively stay current and improve, since the individual believes they already have
sufficient knowledge. Such individuals are also more impulsive and more likely to make risky decisions
because they overestimate the accuracy of their evaluations and the scope of their knowledge. Also
people with such characteristics suffer from a need to be “right” at all costs which makes them unable to
take responsibility for their errors. They do not respond well to criticism and tend to self-justify any
wrong doing and furthermore if they are confronted with evidence of the error they tend to fight the
charges even more tenaciously. Studies done exploring the process of decision making by physicians
showed that physicians are strongly anchored by their earliest decision and it is difficult to get them to
change their plans once they have made them. Social psychologists argue that self-justification and denial
come from the internal conflict between believing your competent, and mistakes, which opposes that
believe. Response: self-deception by self-justification or denial.

Dental students are not immune to the increased Narcissistic traits observed in our culture and could be
even more susceptible to this behavior due to the incredible authority and respect bestowed on them by
the public. In addition dental professional may have the attitude that the implications of a mistake may
not be as serious in dentistry as in medicine so they may be more tolerant of errors and use that attitude to
justify complacency. Considering the gravity of clinical decisions made by dental students, it is crucial for
them to distinguish between a healthy confidence in own clinical ability and a pathological
overconfidence which will be detrimental to their clinical judgment.