Confidence Amid Uncertainty

The dreaded call. An unresponsive patient at the same address where we had been just two hours prior. This patient was well known to us—one of our “frequent fliers.”

The first call was for lower back pain. Initially, she was anxious, tachycardic and unable to sit still. Once we got her to slow her breathing she started to feel better, eventually declining transport. It was the right decision. The ambulance is for sick people, and why waste the emergency department’s time on a busy Saturday?

On the second call, she was pale and hypotensive. We bolused fluid during the rapid transport. In the ED, bedside ultrasound revealed a significantly dilated 8 cm abdominal aorta. The patient was rushed to the operating room for repair of a ruptured aortic aneurysm.

She survived, but what did we miss? Did we overlook important signs and symptoms because we’d been transporting this patient for years with only minor complaints? Did any of us consider vascular pathology as a potential cause for this patient’s lower back pain?

“Real knowledge is to know the extent of one’s ignorance.”

—Confucius

In 1999, psychologists David Dunning and Justin Kruger authored an important study illustrating that people with relatively little experience often mistakenly overestimate their abilities. Paradoxically, with time and practice, one’s confidence level actually decreases, increasing eventually as one nears mastery in their field. Even once expertise is attained, one has an overall lower level of confidence than early in his or her career.

Did I fall victim to the Dunning-Kruger effect? As a newer EMT, I’d never treated a patient with a ruptured abdominal aneurysm and had not considered this diagnosis.

So how do you maintain the appropriate level of confidence? First, perform a clear-eyed assessment of your level of skill, knowledge, and experience. Be humble and put your ego aside. In our field, those who fear humility risk making life-threatening errors by failing to admit uncertainty or accept criticism. Errors and oversights are an inevitable part of our profession, and only by acknowledging our mistakes will we learn from them.

As motivated, well-trained professionals, we have a tendency toward overconfidence, especially in the early stages of our careers. Prior to each patient encounter, actively clear your mind from preconceptions and assumptions. Acknowledge uncertainty and enjoy the steady acquisition of knowledge. The only path to mastery of our field is through years of continuous training and experience, and there are no shortcuts.

Tom Baker, MD, is an attending ED physician at Genesis Hospital, Zanesville, Ohio. Drew Sharrer, RN, BSN, CEN, is a critical care transport provider by ground for Genesis Hospital and by rotor-wing aircraft out of Westerville, Ohio.