In all the tweets and diaries and newspaper pieces I read from doctors and nurses in the lead up to the onslaught of the Covid 19 pandemic, one theme permeated the fear and anxiety. Not becoming ill. Not dying. Not even losing loved ones, but the fear of messing up. The fear of not doing something as it should be done.
What does this say about medical training?
For today I am going to avoid the argument that may suggest it is an inherent but unpleasant part of all large organisations’ leadership styles – the need to keep people siloed, able to feel able only in their small, specialised area, and I am going to focus on the type of education and training clinicians experience.
Once upon a time knowledge was everything. Having a mind like a planet and storing facts was all. Over time we recognised that knowing things was not the same as knowing what to do with those things, and applied knowledge, rather than the poor relation of pure knowledge, became more important. Of course applying knowledge requires skills and I have long said that good doctors probably have the widest and most idiosyncratic set of skills of any professional group we can think of. To cut and to care. To break bad news with the kindness of a stranger. To break ribs in the pursuit of restarting a heart, regaining life. And so our medical education systems focus on knowledge and skills, and within my lifetime have added to the latter category the skills of communication, reflection and organisation. Doctors in training today have perhaps the most comprehensive set of skills to acquire of any era in the history of the profession.
But there is still something missing.
You can be the best doctor in the world, a walking, talking, caring, high achieving master of your art, but if you don’t know that you are so able, it’s all a total waste.
An outstanding but non self-efficacious professional is like a perfectly crafted racing car, with all the essential and high quality components, computers and gimmicks. It might be a collection of the very best parts but if it does not have the correct fuel, it will not go.
Why is it then, that when we see the articulation of complex decision making prowess, when we witness the outstanding skill of a surgeon, or a palliative care physician, we don’t do more to recognise it and appreciate it? I am not talking about the cursory, “Good work,” or “Thanks for that,” often muttered as little more than punctuation in the sentences of busy clinical work. I’m talking about engendering a culture where people know what they can do, and are confident in doing it.
Confidence is a dangerous concept in medicine. Confidence can be good if it is accompanied by equal levels of competence but when it outstrips the competence, it becomes arrogant, ill informed and potentially harmful. Nobody wants a confident but incompetent clinician, so we often do all we can to limit the development of confidence to such an extent that we ignore good practice, engender doubt among our younger colleagues and adhere to the hierarchy which is supposed to stop trainees getting “too big for their boots.”
Self efficacy is not confidence. It is altogether different. Confidence is a person’s own belief on their knowledge and skills, whereas self efficacy is a view about one’s abilities which is based on externally gathered evidence. I may have confidence in myself to be a great detective, given the number of television detective shows I have watched, but I have no external evidence to support that belief, no previous experience of having achieved in that field, so my self efficacy in it is low.
How then do people build up self efficacy?
By knowing that they have done a good job, by seeing the results of it, and by being told that it was good and why and how it was effective. “Nice job,” tells me you liked what I did, but it does not give me any, often necessary, specific information about what was good. It does not help me to repeat it another time or to extract from it the necessary elements to take to a different situation.
Now, more than ever, self efficacy is essential. As we ask clinicians to work in different areas of medicine than they are used to working in, to do different things, and work with new people, we need them to have the courage, confidence and self efficacy to do this.
A colleague recently ran a training session for those additional staff who will be working in the Emergency Department. Along with the knowledge and skills needed for this work, she ended her session with vital reinforcement of their existing capabilities: ‘Remember to start at the beginning – don’t let someone else’s diagnosis lead you down the wrong path;’ ‘mistakes are inevitable – we are here to support you;’ and ‘listen to your gut feeling- if it feels wrong, stop, think and ask for advice.’ Her final point was perhaps the most important of all: ‘Some days you won’t feel like you have done any good at all. This is not true. Patients remember our little acts of kindness more than we know.’
Self efficacy. Reminding people what they can and do do. It’s what we all need at this time, and in fact, all the time. Please don’t confuse it with confidence. In my experience confidence is what is displayed when self efficacy is low, when people are not aware of their strengths, and need to shore themselves up against potential issues.
We work with some excellently constructed racing cars, all components the best they can be, ready to take on the world. Let’s make sure we put the right fuel in their engines.