Educational Perspective
Learner Confidence: Friend or Foe? Richard Gunderman, MD, PhD, MPH, Sean A. Woolen, MS Key Words: Confidence; radiology education; learners; educators. ªAUR, 2014
Life is arduous, difficult, a perpetual struggle. It calls for gigantic courage and strength. More than anything, perhaps, creatures of illusion as we are, it calls for confidence in oneself. Without self-confidence we are as babes in the cradle. Virginia Woolf, A Room of One’s Own Your wisdom is consumed in confidence. Do not go forth today. William Shakespeare, Julius Caesar
C
onfidence is a mixed blessing. In some cases, we are perfectly capable of doing something, and all we need to undertake it is a bit of confidence. A familiar example would be medical students performing their first blood draw or starting an intravenous line. The biggest hurdle is often simply working up the courage to make the attempt. But confidence can also be a liability. In some cases, we physicians do not recognize our own cognitive or technical limitations and end up saying something or attempting something for which we are not adequately prepared. Recognizing the difference between justified and unjustified confidence is an important trait of a good physician. A similar principle applies to learning radiology as a medical student. Most students initially approach radiographs and other imaging studies with considerable trepidation. Prior to medical school, many have never encountered such images firsthand, and even the ones who have done so often received no formal instruction on how to interpret them. At our institution, formal radiology instruction is provided primarily in the second and fourth years—the former in the context of a multidisciplinary introduction to medicine course and the
Acad Radiol 2014; 21:824–825 From the Indiana University School of Medicine, 702 North Barnhill Drive, 1053, Indianapolis, IN 46202 (R.G., S.A.W.). Received October 25, 2013; accepted October 27, 2013. Address correspondence to: R.G. e-mail: [email protected] ªAUR, 2014 http://dx.doi.org/10.1016/j.acra.2013.10.023
824
latter through a required fourth-year radiology clerkship. Students also receive some radiology instruction in their introduction to anatomy course in the first year. Yet we have observed that self-reported student confidence in interpreting radiology examinations increases in the third year, when students are rotating through their clinical clerkships. These include the standard clinical disciplines of medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, and so on. During this year, radiology is not a formal part of the medical school curriculum, and students receive no formal radiology instruction. The increase in their confidence is perplexing, and it suggests that either radiology learning is taking place in informal settings or students are developing confidence in radiology through their study of other disciplines. It is quite possible that students learn some radiology ‘‘on the fly,’’ while helping to care for their patients on other services. For example, a student on an internal medicine rotation might order a chest radiograph to evaluate for pneumonia, then actually review the image with a radiologist and thereby learn something about chest radiology. Likewise, a student on surgery who orders an abdomen/pelvis computed tomography to assess for suspected small bowel obstruction might glean insights into image interpretation in this context. Radiology is an important part of clinical medicine, and it is reasonable to suppose that clinical work exposes students to radiologists and on a fairly frequent basis. It is also quite possible that a good bit of this radiology education is taking place without the direct participation of radiologists. For example, internists, surgeons, pediatricians, and others—but not radiologists—may be doing a substantial proportion of the teaching. It is also possible that students are picking up many lessons more or less on their own, simply by comparing images and reports or reading up on their cases in resources that include radiologic images. Everyone who has ever studied medicine knows that a substantial amount of medicine is self-taught. If students learned only what was presented in formal lectures, their education would be insufficient. There is a danger in allowing too much of radiology education to take place without the participation of radiologists.
Academic Radiology, Vol 21, No 6, June 2014
For one thing, no one understands the field as well as radiologists. Just as no one would argue that radiologists should teach internal medicine or surgery, so no one should expect internists and surgeons to teach radiology. Moreover, students who learn radiology apart from radiologists may tend to develop the presumption that radiology can be done perfectly well without them. They may never gain an adequate understanding of the contributions that radiologists make to study selection and image quality, and they may also fail to appreciate how much other disciplines rely on radiologists’ interpretive contributions. On one hand, we want students to see medicine as a truly interdisciplinary context, appreciating how all the disciplines work together to provide truly integrated and comprehensive care to patients. Their learning should not be restricted to one discipline at a time. On the other hand, we want students to learn from the experts in each discipline, so they see everyone at its best and gain a deep appreciation for the contributions each is capable of making. Medicine is organized into disciplines for a reason, and although such disciplinary boundaries provide some hurdles that need to be cleared in providing optimal care, they also contribute to the excellence of each discipline. A good bit of radiology education may be ‘‘incidental,’’ in the sense that it is not the student’s stated learning objective, but the learning is nonetheless taking place in the normal course of patient care. Students exposed to such lessons are gaining valuable insights into the role radiology plays in daily clinical care. But it is important that students also recognize and respect the limits of such education. Somewhere along the line, someone needs to help them understand the limitations of what they are picking up, no less than the strengths. For example, students who see a few pneumonias over the course of a medicine clerkship should not suppose that they have achieved radiologic expertise. This helps to explain why it is so important for physicians in all disciplines to talk with students not only about what we know well but also about the limitations of our knowledge. Physicians who wish to be perceived as omniscient and never to be seen failing to know something may create false impres-
LEARNER CONFIDENCE: FRIEND OR FOE?
sions among learners, leading them to the naive presumption that they too will soon be know-it-alls. In fact, no physician can know everything, even within the bounds of his or her own discipline, let alone also master the territory of adjacent ones. Good educators not only admit this when pressed but also actively point it out to learners. Simply put, there is no substitute for a healthy level of respect for what we don’t know. Sometimes our discomfort with our limitations can lead us to lay claim to expertise that we don’t really possess. Likewise, lack of familiarity with a discipline or clinical domain can lead us to underestimate its true complexity. In these respects, a little knowledge can be a dangerous thing. It is bad enough for our selfunderstanding, but it is even worse when it leads us to say and do things that put colleagues and patients at risk. Healthy collegiality in medicine means in part that we respect our colleagues and do our best to cultivate a real sense of respect for their cognitive and technical abilities. To address this challenge, one thing we can do is to help learners appreciate the limits of their knowledge. The goal is not to humiliate them but rather to foster the requisite degree of humility. But this same strategy is no less important to apply to ourselves than to students. And one of the best ways to foster such humility in learners and ourselves is to seek out the limits of our knowledge and discuss them openly. Some of the best educators we have encountered have been people who were humble enough to point out their limitations and who sought ways to turn instances of their own ignorance into teaching opportunities. We can teach learners the content of our respective disciplines, but if this is all we accomplish, we will have let them down. For they need to learn to be more than content experts. They need to acquire judgment, the ability to see the difference between what they know and don’t know, what they really need to learn, and what they can safely set aside. This represents a kind of interdisciplinary or even transdisciplinary understanding without which no physician can be entrusted with the responsibility to care for patients safely and effectively. Confidence is good, but too much confidence is no less dangerous, and often more so, than too little.
825
Learner Confidence: Friend or Foe? Richard Gunderman, MD, PhD, MPH, Sean A. Woolen, MS Key Words: Confidence; radiology education; learners; educators. ªAUR, 2014
Life is arduous, difficult, a perpetual struggle. It calls for gigantic courage and strength. More than anything, perhaps, creatures of illusion as we are, it calls for confidence in oneself. Without self-confidence we are as babes in the cradle. Virginia Woolf, A Room of One’s Own Your wisdom is consumed in confidence. Do not go forth today. William Shakespeare, Julius Caesar
C
onfidence is a mixed blessing. In some cases, we are perfectly capable of doing something, and all we need to undertake it is a bit of confidence. A familiar example would be medical students performing their first blood draw or starting an intravenous line. The biggest hurdle is often simply working up the courage to make the attempt. But confidence can also be a liability. In some cases, we physicians do not recognize our own cognitive or technical limitations and end up saying something or attempting something for which we are not adequately prepared. Recognizing the difference between justified and unjustified confidence is an important trait of a good physician. A similar principle applies to learning radiology as a medical student. Most students initially approach radiographs and other imaging studies with considerable trepidation. Prior to medical school, many have never encountered such images firsthand, and even the ones who have done so often received no formal instruction on how to interpret them. At our institution, formal radiology instruction is provided primarily in the second and fourth years—the former in the context of a multidisciplinary introduction to medicine course and the
Acad Radiol 2014; 21:824–825 From the Indiana University School of Medicine, 702 North Barnhill Drive, 1053, Indianapolis, IN 46202 (R.G., S.A.W.). Received October 25, 2013; accepted October 27, 2013. Address correspondence to: R.G. e-mail: [email protected] ªAUR, 2014 http://dx.doi.org/10.1016/j.acra.2013.10.023
824
latter through a required fourth-year radiology clerkship. Students also receive some radiology instruction in their introduction to anatomy course in the first year. Yet we have observed that self-reported student confidence in interpreting radiology examinations increases in the third year, when students are rotating through their clinical clerkships. These include the standard clinical disciplines of medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, and so on. During this year, radiology is not a formal part of the medical school curriculum, and students receive no formal radiology instruction. The increase in their confidence is perplexing, and it suggests that either radiology learning is taking place in informal settings or students are developing confidence in radiology through their study of other disciplines. It is quite possible that students learn some radiology ‘‘on the fly,’’ while helping to care for their patients on other services. For example, a student on an internal medicine rotation might order a chest radiograph to evaluate for pneumonia, then actually review the image with a radiologist and thereby learn something about chest radiology. Likewise, a student on surgery who orders an abdomen/pelvis computed tomography to assess for suspected small bowel obstruction might glean insights into image interpretation in this context. Radiology is an important part of clinical medicine, and it is reasonable to suppose that clinical work exposes students to radiologists and on a fairly frequent basis. It is also quite possible that a good bit of this radiology education is taking place without the direct participation of radiologists. For example, internists, surgeons, pediatricians, and others—but not radiologists—may be doing a substantial proportion of the teaching. It is also possible that students are picking up many lessons more or less on their own, simply by comparing images and reports or reading up on their cases in resources that include radiologic images. Everyone who has ever studied medicine knows that a substantial amount of medicine is self-taught. If students learned only what was presented in formal lectures, their education would be insufficient. There is a danger in allowing too much of radiology education to take place without the participation of radiologists.
Academic Radiology, Vol 21, No 6, June 2014
For one thing, no one understands the field as well as radiologists. Just as no one would argue that radiologists should teach internal medicine or surgery, so no one should expect internists and surgeons to teach radiology. Moreover, students who learn radiology apart from radiologists may tend to develop the presumption that radiology can be done perfectly well without them. They may never gain an adequate understanding of the contributions that radiologists make to study selection and image quality, and they may also fail to appreciate how much other disciplines rely on radiologists’ interpretive contributions. On one hand, we want students to see medicine as a truly interdisciplinary context, appreciating how all the disciplines work together to provide truly integrated and comprehensive care to patients. Their learning should not be restricted to one discipline at a time. On the other hand, we want students to learn from the experts in each discipline, so they see everyone at its best and gain a deep appreciation for the contributions each is capable of making. Medicine is organized into disciplines for a reason, and although such disciplinary boundaries provide some hurdles that need to be cleared in providing optimal care, they also contribute to the excellence of each discipline. A good bit of radiology education may be ‘‘incidental,’’ in the sense that it is not the student’s stated learning objective, but the learning is nonetheless taking place in the normal course of patient care. Students exposed to such lessons are gaining valuable insights into the role radiology plays in daily clinical care. But it is important that students also recognize and respect the limits of such education. Somewhere along the line, someone needs to help them understand the limitations of what they are picking up, no less than the strengths. For example, students who see a few pneumonias over the course of a medicine clerkship should not suppose that they have achieved radiologic expertise. This helps to explain why it is so important for physicians in all disciplines to talk with students not only about what we know well but also about the limitations of our knowledge. Physicians who wish to be perceived as omniscient and never to be seen failing to know something may create false impres-
LEARNER CONFIDENCE: FRIEND OR FOE?
sions among learners, leading them to the naive presumption that they too will soon be know-it-alls. In fact, no physician can know everything, even within the bounds of his or her own discipline, let alone also master the territory of adjacent ones. Good educators not only admit this when pressed but also actively point it out to learners. Simply put, there is no substitute for a healthy level of respect for what we don’t know. Sometimes our discomfort with our limitations can lead us to lay claim to expertise that we don’t really possess. Likewise, lack of familiarity with a discipline or clinical domain can lead us to underestimate its true complexity. In these respects, a little knowledge can be a dangerous thing. It is bad enough for our selfunderstanding, but it is even worse when it leads us to say and do things that put colleagues and patients at risk. Healthy collegiality in medicine means in part that we respect our colleagues and do our best to cultivate a real sense of respect for their cognitive and technical abilities. To address this challenge, one thing we can do is to help learners appreciate the limits of their knowledge. The goal is not to humiliate them but rather to foster the requisite degree of humility. But this same strategy is no less important to apply to ourselves than to students. And one of the best ways to foster such humility in learners and ourselves is to seek out the limits of our knowledge and discuss them openly. Some of the best educators we have encountered have been people who were humble enough to point out their limitations and who sought ways to turn instances of their own ignorance into teaching opportunities. We can teach learners the content of our respective disciplines, but if this is all we accomplish, we will have let them down. For they need to learn to be more than content experts. They need to acquire judgment, the ability to see the difference between what they know and don’t know, what they really need to learn, and what they can safely set aside. This represents a kind of interdisciplinary or even transdisciplinary understanding without which no physician can be entrusted with the responsibility to care for patients safely and effectively. Confidence is good, but too much confidence is no less dangerous, and often more so, than too little.
825
