• Tyler Christifulli

The Illusion Of Knowledge


One of the most frustrating parts of being a clinician is when your perception of knowledge outgrows your clinical experience. This is graphically illustrated by the first large peak of the commonly referenced Dunning-Kruger effect chart. This is when a clinician has way more confidence then actual experience. We commonly look at this D-K effect as a bad thing, but rather maybe it’s just the normal progression of mastering a craft. I would argue that this perceived confidence is not driven from ego, but rather the effect of didactic or self directed learning.

The interesting part of this graph is that it actually has very little correlation to the actual paper written by D-K. However the graphic has become more popular than the actual paper. People will identify themselves through self assessment as almost always being in what I call "The Hammock". While this graph may not be an accurate representation of the D-K concept, it does represent a normal progression amongst providers. I propose that we quit calling it the D-K effect, and start recognizing it as a path to expertise.

Consider this example. A new critical care paramedic purchases a copy of Marino’s ICU Book. As he is trying to further his knowledge in the inter-facility arena, he comes across a chapter on calcium channel blocker overdoses. In this chapter it describes the use of calcium, atropine, glucagon, and even pressors. However this chapter concludes by saying that the use of high dose insulin therapy is very effective and should be considered early in this toxidrome. This sparks curiosity and further research is done on this therapy. The reviews astonishing, several well done studies show its efficacy, and there is even several podcasts with very credible doctors discussing their success with it.

This therapy and toxidrome is now perceived to be the fix for patients who are crashing from calcium channel blocker overdoses. You know the dose, the procedure, benefits, and risk. There is a perceived level of knowledge on how this could work if you ran into this scenario in a small critical access hospital. You envision talking through this procedure with the referring physician, and even how you would manage it on transport. This sounds like a proactive clinician who is thinking out the logistics of advanced resuscitation scenarios. So what’s the problem?

The problem lies in the fact that you possibly have never even cared for a crashing calcium channel blocker overdose. You are building a knowledge base, logistics, and in some ways confidence in a scenario that you may only come across a handful of times in your career. Is this disproportioned experience/confidence ratio a sign of what Weingart calls a “resuswanker"?

Would you rather informed and inexperienced, or uninformed and inexperienced. Some may perceive the latter to be the safer route, but how long does this lack of confidence need to occur before it is elevated? Is this granted confidence based off years, experiences, or arbitrary? Is it even confidence that we are really referring to along the Y axis?

There is a ton of evidence to support the idea that an individual will perform better with a procedure if they imagine themselves being successful. This is without a doubt confidence with or without the experience.

History is full of special forces, professional athletes, and random civilians who performed at extraordinary levels with never have been in those situations before. I commonly think of Seal Team Six who had never even stepped foot into Osama bin Laden’s compound before navigating precisely to his location. The path had been mapped out to the best of the CIA'S ability, but they had never been in that situation before. So how do they pull it off?

It was stated by one of the team members that they had rehearsed this plan in a mock compound in North Carolina over one hundred times over the course of three weeks. However, during the first phases of this executing this plan the team met their first unpredicted hurdle. The helicopter became caught in turbulence from its own downwash. It is believed that this downwash was magnified and reflected by the compound walls. It was also expressed in a documentary of this mission that they had not rehearsed with sheets covering the entrance way as opposed to actual doors. This was found to be another variable that they were able to adapt and overcome.

Over one hundred rehearsals and there are still variables that can't be planned for.

I believe there are some run offs of situations you have experienced that make you better at those that you haven’t. For example, a person who learns to play the guitar has a very shallow learning curve when it comes to learning the bass. However a guitar player who picks up the bass could be seen to be at the peak of the high confidence and low experience “mount stupid” on the graph above. They have experience as a musician, but not with that instrument.

We are expected to perform at incredibly high levels under sometimes stressful conditions. We can not wait for experience to be good at our job.

Let that sink in.

The trick to taking a text book chapter, simulation, and mental simulation to practical application falls on the shoulders of the provider.

I have an exactly 70 minute drive to work three days a week. My drive home consists of listening to Red Hot Chili Peppers with the volume turned up as loud as my mini van handle. Here is how I layout my drive TO work.

20 Minutes - Podcast

10 Minute - Khan Academy Science Video

20 Minute - Mental Simulation (silence with just me imagining in incredible detail the logistics of a mission)

20 Minute - Silent Meditation

My mental simulation usually brings up questions that I will try to answer that shift.

Questions like:

What side of my jump bag is the adult BVM vs ped BVM.

Whats the highest glucose my EPOC will read?

Whats the smallest tube I can fit over my pediatric bougie?

The more specific your question you bump into during mental sim, the better! These techniques are incredible and will increase your confidence in caring for patients in many different scenarios. However, you will always forget something in your simulation that will pop up in real life. I believe this is where the "hammock" of the graph above begins. Reality knocks the wind out of you and the normal progression of decreasing confidence ensues.

This is in my opinion a normal progression that occurs many times throughout our career. We can't be experts on everything. We will hit peaks and troughs many times in confidence and ability. The secret is being aware, actively moving forward, and learning from mistakes.

I have heard many FTO's state that someone is "not cut out for this job." This was said about me 10 years ago by my FTO at my first EMS organization. If you want to be good at something, only you can make it happen..

Further Reading

Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments.https://www.ncbi.nlm.nih.gov/pubmed/10626367

Why Incompetent People Think They're Awesome

https://arstechnica.com/science/2016/11/revisiting-why-incompetents-think-theyre-awesome/