The Arrogance of Competence

I’m arrogant—at least I think I am. I certainly have been guilty of acting in an arrogant manner and been accused of being arrogant by others. How did this come to be? It’s never been a goal of mine. It’s possible that it is a part of my personality, deeply encoded somewhere in my DNA.

In my deepest moments of introspection, I can only place the blame for arrogance squarely on my own shoulders. Which brings me back to the question: How did this come to be?

I think at least part of the answer to that question is found in my career in EMS—a career that places people like you and me in high tension and high adrenaline environments and only appeals to a certain type of person. When we live through that, we have immeasurable pride in what we were able to do

I am not suggesting that we shouldn’t take any pride in what we do. But the very nature of our EMS world creates a pretty particular trap for us that can create dire consequences for the people we serve. While many people in many professions can fall into this trap, it seems that those of us who are called to EMS struggle with this more than others. Perhaps I am simply more aware of the trap and our profession, since I have fallen into it myself, and have seen others whom I have known and admired in the same trap with me.

I am speaking of the trap of arrogance created by our own competence—the arrogance that comes with the assumption that we are now competent, only to discover that we were not as competent as we thought. If we were engaged in a profession that involved only ourselves, this arrogance would not be nearly as dangerous as it seems. But our profession, and all those that are engaged in the practice of medicine, opens all of the people around us to the same trap. The people that are affected by this are not just the patients for whom we are immediately providing care, but also their family, neighbors, community, your partner and even your particular EMS agency.

The best illustration of this is from my own experience. I spent the majority of my career in a fairly busy urban system. We responded to over 25,000 9-1-1 calls a year. New paramedics in our service cut their teeth very quickly. Treating gunshot wounds was commonplace. A heart attack victim was just another day on the job. We knew what to do, and we did it well.

The provision of rapid sequence intubation was a skill reserved to an elite few supervisors. When an RSI is performed, the paramedic has determined that even though the patient is breathing, the patient will be better off if the paramedic removes the patient’s ability to breathe on their own and takes over that responsibility on behalf of the patient. Consider that for just a moment: the paramedic is essentially saying, “I know what you, my patient, needs right now, and I am going to deprive your body of its natural ability to sustain life so I can do what I think needs to be done.” That my friends, is a significant decision.

The paramedic must rapidly make the decision of whether to perform the RSI or not, and they are often the only person on which they can rely for consultation. Success or failure, the paramedic will own it all. The stakes are high. If the paramedic is unsuccessful, the patient that was breathing is now completely incapacitated and unable to breathe. The patient is utterly dependent on the EMS crew to be competent.

When I was promoted to the ranks of those whom were trusted to perform this skill, I was very impressed with myself. I will readily admit that I was also intimidated, wondering if I were really up to the task. During the first RSI I performed, my heart was pounding and brow sweaty. The second one was easier. The third easier still. And so on. One day, I decided I was competent. I could do this, and very few others could. I was saving lives. What I didn’t realize was my arrogance was outpacing my competence.

One day, my patient again needed the assistance that only I could provide. She was struggling desperately to breathe. I did the exact same thing I had done so many times before. As I opened my patient’s airway I looked for the glottic opening, searching for the tell-tale landmarks of her anatomy.  They were nowhere to be found. I might as well have been looking into the depths of outer space and trying to determine the edge of the galaxy.

Suddenly, I felt more anxiety than I had on the first RSI I had ever performed. Except that now the anxiety was not caused by wondering “Can I do this?” it was caused by the realization that “I can’t do this.” Fortunately, I remained calm enough to simply assist the patient with breathing and wait till the drugs I had given her had lost effect. She recovered, and I simply provided what assistance I could on the way to the hospital. She survived in spite of me.

Should I have done it? Maybe. Maybe not. It’s hard to look back at a situation like that and second guess my decision, but in retrospect, there were indicators that suggested I should have used better judgement. She was not tall, and a bit overweight. I didn’t use the Mallampatti test, and more importantly, I was less than 10 minutes from the emergency room. The decision to perform the RSI was probably a poor one. At the very least, it was a decision that could have been better informed.

I walked away from that call with a stark understanding: Despite all of my tools, despite all of the drugs at my disposal, despite my experience and despite my competence, I was just as fallible as anyone else. My own arrogance endangered that patient.

If you had asked me just prior to my encounter with my patient whether I knew how to perform an RSI, I would have answered yes. If you had suggested that you had learned some new techniques for RSI or had some thoughts on the decision making process, I might have pretended to listen to you while in my mind I was trying to decide whether I was going to have tacos or a burger for lunch. I know I would not have been receptive to anything you or any other “subject matter expert” had to say. Why should I? I knew I was competent, because I had proven myself right over and over and over again.

We so easily fall prey to believing that we are more than we are. We look around us and see thousands of dollars of equipment, neatly organized. We know what each item is and what it does. We have a uniform, a badge, a patch, a card in our pocket. We perform the same tasks over and over, day in and day out. Everything in our environment and everyone we know tells us we are competent. We are a cut above the rest. We do have value and we do have purpose, but we are still human. We still have the same emotions we had yesterday, the same character flaws and the same arrogance. In that arrogance lies danger for your patients and for you.

I don’t want you to hear me say that you should not be bold when the situation calls for it. I don’t want you to hear me say that you should not trust your instincts, your training or your education. You must do all of those things, and if you cannot do them, then you must find a new career. You should be proud that you have received such a calling. Very few are capable or willing to do what we do.

I do want you to hear me say never believe that you are as competent as you can get. Never believe that there is nothing left to learn. Don’t fall prey to your own hype. There is no shame in doubt. There is no shame in asking questions. There is no shame in making a mistake. I will not be so arrogant as to suggest that my few words will prevent you from ever making the mistakes I have. You will make them as well. Your competence will be defined by what you do after you fail.

The only shame is in forgetting that you are capable of failure, and that failure could mean the difference between life and death. A patch does not make you competent. Neither does a uniform or lots of initials after your name. All of these are simply symbols that give an illusion of competence. They give you, the individual paramedic or EMT, absolutely nothing in the care that you provide.

Will you be competent? Yes. You will most certainly achieve a level of competency as you gain experience and knowledge. But you will never be done gaining that knowledge and experience.

A good friend and EMS colleague of mine has a quote attributed to Annabel Monaghan attached to all of his emails that reads: The truly educated never graduate. My friend lives this in all of his pursuits and constantly seeks out whatever new knowledge might come his way. He just turned 70 years old.

We are blessed to do this work. People willingly ask us to be part of the worst day of their life. They trust us because we enter their lives with a confidence and presence that says, “You can trust me to take care of this problem for you.” That is true, we can help them. But being a good, competent paramedic or EMT means that you hold that trust sacred and inviolate.

Hold that sacred trust above any demand from your employer, any duty you owe to your partner, and most importantly, above any perception you have of yourself. Remember, this is not simply another patient, another skill to be performed or another drug to be given. This is someone’s mother or father, sister or brother, a son or daughter. That is a sacred thing: to be trusted to care for someone who someone else loves.

Remember your first EMT class? Remember how eager you were to soak up that knowledge? Remember how you sought out every bit of information that you could find? Arrogance is a disease that convinces you your student days are over. Honesty with yourself is the cure, and education is the path to real competence.    

Never give up the pursuit of excellence. Never accept mediocrity. Never assume you have arrived. Never graduate.

Andy Gienapp is the current EMS manager for the Wyoming Office of Emergency Medical Services. A paramedic with over 28 years of EMS experience, Andy has functioned in a variety of clinical and out-of-hospital settings. As the Wyoming EMS Manager, Andy is an active member of the National Association of State EMS Officials (NASEMSO), serving as the Western Region Representative, the Vice Chair of the Rural and Frontier EMS Committee and as an appointee to the Continuing Education Coordinating Board for EMS (CECBEMS). He is a 23-year veteran of the US Army Medical Department and has served in numerous assignments, to include two tours of duty in the Iraqi theatre. Andy holds a Master of Science in Emergency Health Services from the University of Maryland–Baltimore County.