In last week’s edition of Practice Perfect we talked about confidence and the importance of having an authentic self-confidence. Having a lack of confidence, whether expressed as false overconfidence or tentativeness during a particular action, can have significant ramifications.

For example, a novice resident who enters the operating room with an air of underconfidence runs the risk of making the procedure more difficult for themselves. The attending surgeon will see the lack of confidence and be unwilling to hand the knife to the resident. This sets up a less than optimal learning experience. Additionally, the rest of the surgical team will perceive this lack of confidence, with a negative effect on the team.

In the psychological literature “positive performance expectations” (AKA self confidence) are created when the perceived resources (one's ability to accomplish an activity) exceed the perceived threat (the action to be completed), which is termed “self-efficacy”.² Self-efficacy is what we are trying to build in our trainees.

As student and resident educators, attending physicians must constantly deal with situations like this, and it behooves all of us to help our trainees gain that all-important authentic self-confidence. Any method that improves authentic confidence, then, would be important for us to understand. A nice framework for this process comes from psychologist Albert Bandura’s social cognitive theory, an idea that people learn by observing others¹ According to Bandura, there are four components to build skills, including:

How can we apply this information to helping our trainees build self-confidence?

Modeling

According to social cognitive theory, a learner acquires knowledge by observing others³, a well-known set of recommendations called “peer modeling”⁴ or “social monitoring”.² Just as our very young children observe and then model our behaviors as they grow, so too do trainees model what their educational leaders do.

In my own experience as an educator, I have found this to have a powerful effect on trainees. For example, I spend a lot of effort during clinics and educational sessions advocating for a skeptical and questioning attitude toward information. I tell them, “Don’t just believe what everyone tells you. Do the research and find the answer for yourself”. I emphasize that this philosophy includes me, and as a result, when the residents become more experienced, they question everyone. For those attending physicians who are less secure in their views, this can be troublesome, and the residents have to learn to moderate their questioning (at least to those particular individuals).

Similarly, if we want trainees to be self-confident, then we have to model that same confidence. I try to adhere to this by verbalizing my reasoning and being self-critical. For instance, if I had a less than optimal outcome after a surgical case, I don’t hide it. Instead, during case discussions, I verbally analyze what could have been done differently and what I learned from the case. It takes some level of confidence to admit your shortcomings and grow from mistakes, and I model this behavior to the residents.

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It takes authentic confidence to admit your shortcomings and grow from mistakes

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Outcome Expectancies and Self-Efficacy

Our trainees must understand the results of an observed behavior if they are going to repeat that behavior. What better way to understand the results than to repeat a positive behavior several times in a safe environment? In the past, I have advocated for a true competency-based training method, and beside the ability to assess our trainees with this method, a not so ancillary benefit is the boost in confidence that occurs. One of the key educational approaches of competency-based education is the use of simulations. Consider the obvious improvement in operating room confidence if a resident has performed, say, 30 first tarsometatarsal fusions on cadavers or sawbone models before ever doing the procedure on a patient. It sounds good right? But is there evidence to support this idea?

Geoffrion and colleagues recently demonstrated an improvement in confidence in novice gynecology residents randomized to either a competency-based education module prior to performing certain gynecologic procedures or not receiving the module prior to performing the procedures.³ They found a significantly greater increase in confidence in those residents who had not previously performed the procedures, with a smaller confidence increase in those who were more advanced in training. This makes good sense if you consider that the more experienced residents had already built greater self-efficacy through their prior experiences so would have a shorter distance to go to be confident than those with no prior experience. They had more general experience from which to draw.

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Evidence exists that a competency-based training leads to greater self-confidence

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This research directly represents Bandura’s recommendations to increase self-confidence via mastery experience. In this method, an individual repeats simple tasks at first, which progress to increasing complexity. Geoffrion and colleagues simulations were simple in nature, emphasizing fundamental concepts.³ Mastering these techniques and fundamental skills led to a greater jump in their trainees’ self-confidence.

Identification

Trainees will learn better if they more closely identify with their model. It then behooves our trainers to get to know our students and residents to create emotional attachments that lead those trainees to follow our lead. Perhaps the good old Golden Rule should come in here.

Along the same lines as identification, Bandura recommends improving self-confidence by ensuring trainees are well-rested and relaxed when they learn a new task or skill.² For my more experienced residents, I allow music in the OR. This creates a more relaxed environment both for the resident and me. Surgery can be stressful and establishing a somewhat relaxed environment is highly beneficial. I don’t recommend this for novice residents because music has been shown to increase cognitive load during new tasks.⁵

Finally, “verbal persuasion” is also helpful to build self-confidence. This is simply providing verbal encouragement that the trainer believes the trainee is capable of performing the task in question. When was the last time you provided this type of encouragement before a surgical case? It might sound corny, but consider giving your low confidence resident a pep talk before that next complex surgical case.

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Consider giving your low confidence resident a pep talk before that next complex surgical case

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Let’s finish this discussion with a quick, high-yield review of how to help our trainees become more self-confident:

Recall that our goal as trainers of students and residents is to create the best doctors possible, and that means not just as clinicians or technicians but also as people. That improvement starts with building confidence.