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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Wednesday 5 May 2010

Incompetence, Feedback and the Kruger-Dunning Effect

August 2010 will see an interesting turn of events. Not only do the 180-odd newbie radiology registrars recruited by national selection start their training but also workplace-based assessment begins in radiology.

Whilst I heard nothing but praise for the former, I’ve heard plenty of grumbling about the latter. Trainees are embittered from previous experience of it as a Foundation Doctor. Trainers are wary of extra workload and all the acronyms. I’m supportive of these concerns but the underlying educational message seems to be lost in all this negativity. Namely, that workplace-based assessment is best seen as a way of giving better feedback.

Recently, a registrar listening at my knee (we can’t afford chairs in my hospital) asked me for feedback. I explained that I didn’t have my electric guitar with me; the registrar fish-mouthed and the joke made an attractive centre-parting as it sailed over their head.

Most trainees appreciate feedback; a recurring criticism is they don’t get enough. I heard of a consultant who stopped giving feedback as they were tired of making their trainees cry. Apparently, to appear balanced and fair as a trainer we need to give 5 positive to 1 negative bit of feedback. So, being Dr Nice Guy is about right.

The type of trainee that really interests me is the particularly thick-skinned individual who is seemingly impervious to feedback. They listen but don’t seem to hear. I’m not talking about the common-or-garden pig-headedness typically seen in ex-surgeons. The (thankfully) rare individuals that I am fascinated by also have an indefensibly high opinion of their own abilities but are often shockingly incompetent.

Perhaps you can think of a similar individual you have trained or trained with. They are a real worry mainly as you don’t know where to start. Well, I’d been musing about this for some time when I had an epiphanic moment. Earlier this year I read of the ‘Kruger-Dunning’ effect and it all slotted into place.

US psychologists Justin Kruger and David Dunning performed an elegant series of experiments in the late 1990s to study human incompetence [1]. Using a diverse set of tasks they showed that incompetence is worse than it appears to be. It forms an unholy trinity of cluelessness: the incompetent not only overestimate their own level of skill but also fail to recognise genuine skill in others and, even after feedback, fail to recognise the extremity of their inadequacy.

Furthermore, they found that the most competent underrated their abilities. This group were aware of their abilities but they overestimated the abilities of others. Subsequent studies have confirmed this affects many real world settings, medical trainees being no exception.2

On digging a little deeper, it appears that Kruger and Dunning (who, incidentally, won an IgNobel award for this research in 2000) have merely crystallised and quantified the wisdom of our forebears, both recent and ancient.

For example, Confucius observed, ‘Real knowledge is to know the extent of one’s ignorance.’ Jeremy Taylor, a 17th century English priest, wrote, ‘It is impossible to make people understand their ignorance; for it requires knowledge to perceive it and therefore he that can perceive it hath it not.’ In 1871, Charles Darwin observed that, ‘Ignorance more frequently begets confidence than does knowledge.’ And then there’s the British philosopher Bertrand Russell (who, ironically, never suffered much from self-doubt) who said, ‘The trouble with the world is that the stupid are cocksure and the intelligent are full of doubt.’

So, can people ever form accurate self-impressions? Probably not, it seems. Can we become aware of our intellectual and social deficiencies without outside intervention? Possibly. The Ancient Greek aphorism of ‘Know thyself’ is a bit harder than it seems.

There is one consolation to this rather nihilistic tale. Kruger & Dunning found that if you trained those who were found to be incompetent, they began to develop insight into previous performance. So perhaps there is a positive take home message. If you come across an over-confident but duff trainee with a skin as thick as hide, don’t give up on them. Protect them from themselves, train them and they will get it eventually.


1) Kruger J & Dunning D (1999). Journal of Personality & Social Psychology. 77, 1121.
2) Hodges et al (2001). Academic Medicine. 76, S87.

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