Some skills are absolutely integral to the success of each of us as individuals. For surgeons, one of these might be three-dimensional appreciation or hand-eye coordination. For scientists, an essential skill is logical thinking. However, other skills are less concrete but just as important for all of us. Take communication skills as an example. Without the ability to convey our needs and desires, we will never be truly successful. Another of those very important, but less tangible skills, is confidence.

In my time as a teacher, I have found confidence to be one of the most important – and often difficult to truly acquire – skills. Let’s talk a bit about confidence and see if we come to a working understanding of this skill and how we might improve our own and others’ confidence.

Definition

Since a definition is always a good place to start, why don’t we “go back to the beginning,” as Inigo says in one of my favorite movies, The Princess Bride. “Confidence” is defined as “a feeling or consciousness of one's powers or of reliance on one's circumstances” or “faith or belief that one will act in a right, proper, or effective way”.¹ In effect, you know that you are able to handle a particular task because you are aware that you have the knowledge and skills to do so.

We encounter situations where we lack confidence all the time. However, how that lack of confidence exhibits itself varies. The difference seems to be what’s at stake for the person in a particular situation. For example, I didn’t know the exact definition of confidence when I started writing this. I was unconfident, so I looked it up from a source I am confident in – Merriam-Webster, the well-known dictionary - and added it to this editorial. As everyone knows, I am not a walking dictionary (no one is); the stakes for me not knowing the definition are low.

However, what if I lacked confidence in how to handle a particular foot and ankle pathology? As a podiatrist, this has higher stakes. Let’s say I’m seeing a hypothetical patient who needs surgery for their chronic lateral ankle instability. We discuss a Brostrum procedure, and the patient has an expectation that as a foot and ankle expert, I should be able to perform this procedure successfully. Let’s also say, hypothetically, that I don’t know how to do this procedure well. Maybe I didn’t receive strong training in this procedure, or it’s been many years since I last did one. Either way, I secretly lack confidence. I have two responses to this situation. One, I can be honest with the patient, relaying my lack of experience or training. Or two, I can pretend I know what I’m doing, relay a false impression to the patient, and do the surgery. For anyone who has a reasonable sense of self-knowledge and confidence, the correct answer would be number one. Tell the patient you’re not the best person for the job and refer her to someone who is.

This is actually the situation for me when it comes to total ankle replacements. I have neither the training, experience, nor necessary patient volume to feel confident about this procedure, so I refer any patients who need this surgery to someone else. I’m ok with myself and have no trouble admitting this fact. Clearly the stakes are very high (another person’s health), and I’d rather everyone be aware of my inability to do this procedure than one patient be injured unnecessarily.

Human Nature

This is where so many people get themselves in trouble. Although it may seem obvious to everyone reading this to just do what’s best for the patient and be confident in ourselves, in reality, the opposite is true. I constantly witness situations where people either lie to themselves or others in order to hide their lack of confidence. I see teachers who pretend to know more than they do to prevent a perceived embarrassment when their ignorance is revealed. I see surgeons who go beyond their capabilities and do procedures they should have referred to others. I see other healthcare providers treat patients poorly because they are either too ignorant or too overconfident to stop and ask for help.

Here’s an example. I see a large number of diabetic wound patients in my practice, and I use negative pressure wound therapy (NPWT) for some of them. I have about 15 years of active experience with these, received training, and have witnessed my own failures and successes. In my experience, there’s basically one correct way to put on a NPWT system and a bunch of wrong ways. This isn’t false confidence. I have a very high success rate using these systems and am confident in my ability to achieve successful wound healing with them. If someone has a better way to use them, then I’d be happy to learn.

Never, Ever, Stop Learning

This is why it’s so very frustrating when I use certain home health agencies to do NPWT changes for patients at home, and the nurses apply them incorrectly. Now, I’m sure there are lots of great home health nurses, but in my area, many of them are incapable of correctly applying the dressing. Unfortunately, the response my patients and I receive when we attempt to communicate with these nurses is, “I know how to apply one.” They shut down and won’t admit their ignorance. I’ve had to fire several home health agencies as a result.

Overconfidence

This brings us to the idea of overconfidence. This is really just another facet of a lack of confidence. Acting overconfident is often just another way to hide one’s secret lack of self-confidence, knowledge, or skill, or a fear of being embarrassed. This is also seen during medical student and resident education with the well-known scenario. After discussing a particular medical issue, the attending physician asks the trainee, “Do you understand?” If the student doesn’t know what the attending is talking about, they will still answer, “Yes.” Instead of appearing ignorant, the trainee will essentially lie by stating they understand, thereby eliminating the opportunity to learn. In this case, false overconfidence hides potential embarrassment.

As we can see, confidence is a complicated and multi-faceted personal characteristic with potentially very harmful effects. I can’t do much to fix the hidden lack of confidence of those already in clinical practice, but those of us responsible for training others have a wonderful opportunity to help our trainees build true positive self-confidence. How we do that for both ourselves and others will be the subject of next week’s Practice Perfect.