Is Confidence Overrated in Medical Practice?

The following transcript has been edited for clarity and brevity.

Eric J Topol, MD: Hello. I'm Eric Topol, editor-in-chief of Medscape. It's quite a privilege for me to have a discussion with Nicole Treadway, a fourth-year medical student at Emory University, who wrote a spectacular essay^[1] on the confidence gap in medicine, which was published in the October 16 issue of Annals of Internal Medicine. Nicole, welcome to Medscape One-on-One.

Nicole Treadway: Thank you so much. It's really a pleasure to be here.

Topol: Nicole, maybe you could start by summarizing what you wrote about, because I'm sure many of the Medscape folks have not had a chance to read your essay.

Treadway: This essay was inspired by a personal experience I had, along with experiences of several female colleagues I had spoken with. It came about quite organically. We were having dinner one evening and discussing some of the recent criticisms we had received during our third-year clerkships. One woman shared a comment she'd received. She had presented a patient on rounds and was given a compliment on being thorough in her presentation, but afterward, an attending told her that he wished she had presented with more confidence.

The group's reaction was interesting. As soon as she said that, we all recognized similar experiences that we'd had on the wards. Also similar, the experience had bristled, but it wasn't exactly clear why. So I turned to the literature.

I had two questions about the comment that she should be more confident. The first was whether it was gender related. These were women who were not recently out of undergraduate school. They were nontraditional students who had worked in other careers. I would say that none of us necessarily identified as "non-confident." It felt like a surprising comment, and it wasn't something I had heard from male counterparts. So that was the first question I had.

But really, it prompted me to consider the value we place on a confident style of presentation. Most of my essay is about this. Given the shift in culture in medicine—moving away from an assertive, potentially paternalistic tradition of medicine toward a more collaborative tradition, where we see a real partnership model with our patients come into play—I thought it was worth reconsidering and taking a step back to examine the value in that message, to "be more confident."

Topol: It was inspiring, Nicole, and it touched many of the pertinent readers, I'm sure; also the Twitter response was extraordinary, with hundreds of people coming on board to say that this is real. We will get into the gender issues, but it goes beyond that. As you've just pointed out, it's about this whole idea of incorporating patients into their decisions and not being so paternalistic and assertive. This is a deep issue in medicine.

Perhaps we can start with the gender issue. There is a concern that we have a lot of male attending physicians who are influencing med students and expecting these students to exude confidence. I suspect that there may be male students who are affected as well. It's as if it's almost better to be confident and wrong! Would you say that this is something that's not just gender related, but it's that attitude that strongly conveying assuredness is preferred?

If it's true that women are less confident than men, perhaps this creates a culture of patient safety and improved learning.

Treadway: I think you're right. That is the prevailing, or formerly prevailing, cultural value: Better to be wrong and say it confidently. I have not found, through my perusal of the literature, that the comment itself is gendered.

However, I did find compelling evidence that there is a "confidence gap" between men and women physicians. Actually, this does not just encompass physicians; I found this to be an interdisciplinary issue. It's found among economists and other academics, in business, and among trainees and professionals.

Although studies have found that men and women are quite comparable around their competence and abilities, we see a pattern whereby women have a tendency to predictably and reliably underassess their own performance. It's surprising. Not only has it been found in self-reports, but also in some retrospective reviews and cases by independent observers who have rated female trainees less confident compared with their male counterparts.

I did not find the evidence to show that this feedback—to be more confident—is given primarily to women, although I believe that other groups have demonstrated that we do see a lot of gendered language in medicine. Certainly at my own institution, we are talking a lot about the type of language individuals use when describing their students on evaluations. There was a paper in 2007 by Lee and colleagues^[2] that showed that students who were less assertive in their communication got poorer evaluations. Though it was not causal, it was worth considering.

It's a timely question. I believe that accounts for the robust Twitter response to my article, which really took me by surprise. It was astounding to see it resonate with so many individuals.

Topol: I love the way you brought in other sectors, not just medicine. For example, Sheryl Sandberg's Lean In book^[3] and her whole movement show that it isn't something that occurs only in healthcare and medical school.

I completely agree that it isn't necessarily only a gender story but that the gap overall is a big deal. In my experience, women in medicine are simply more reflective. They are less assertive in general. This is a good quality, and as you pointed out in your essay, it's associated with better outcomes.

Treadway: It might be. We don't know for sure. As more women enter medicine and we see, if not better outcomes, then certainly comparable outcomes, I think it's worth reconsidering what women bring to the table. Rather than taking Sheryl Sandberg's approach, telling women to lean in, speak up, act more with these traditional, somewhat male displays of professionalism, maybe we need to reconsider the benefits of the approaches that women bring.

Maybe it's time to adopt a cultural change, to value those qualities differently. Even if it is true that women may be less confident than men, perhaps this creates a culture of patient safety, of improved learning. Maybe there are unseen and unexamined benefits here that we should focus on.

I want broader training on how to be flexible as physicians.

Topol: That sure seems to be the case. One of the other aspects I wonder about is this culture that has been cultivated throughout medicine for a long time, perhaps millennia; is this an outgrowth of paternalism? The point that we need to be less paternalistic with patients tends to be more associated, although not exclusively, with female physicians than male physicians. Do you believe we're headed toward the end of paternalism?

Treadway: It's a difficult question. I would like to say yes, but I've received a number of comments that have pointed out that for some patients and in some circumstances, that approach can be effective. Not necessarily being paternalistic, but maintaining an element of assertive opinions, offering assertive opinions or presenting a certain level of composure, which in some ways makes sense. It's easy to promote partner decision-making, perhaps, especially when you're in the clinic discussing a patient's priorities and values, but perhaps less so when a patient is acutely ill in the ICU with a poor understanding of the disease process.

I'm all about nuance ultimately. What I'm arguing for is more tools in the toolbox. I want broader training on how to be flexible as physicians to meet the needs of all of our patients, patients who prefer different models of care, and physicians who, even within the same patient's lifetime at different points of care, can adapt and effectively manage what that patient needs in the moment.

That may not be quite the decisive answer you were looking for. I do think we are seeing a shift away from paternalism. As to the value of this partner-in-health approach at all times, I want to give a little credit to some of the critiques I have received. I openly acknowledge that different patients in different times require different skillsets.

Topol: What persuaded you to submit the essay to Annals?

Treadway: To be honest, it was prompted by my husband. This was something I sat down to write because it was floating around in my brain. I did not have a publication in mind.

Speaking of my own issues with confidence, I did not necessarily believe that it would have a national platform like this. I was looking at smaller publications initially. I shared it with those around me and they immediately saw something of value.

Topol: This experience also underscored an important trait in medicine, which is astute observation skills and the fact that you were at that gathering with fellow students and this resonated. You all were making an important observation that hasn't surfaced, in my view, until it was addressed by you. There's so much, of course, about disparate pay and other matters, but the actual point about confidence was masterfully done.

What's your future? Where are you headed in medicine?

Treadway: I very much would like to end up in an academic center practicing internal medicine. I do see myself as a future primary care doctor, but I appreciate that my heart may be captured throughout the process by something else. I'm going in with an open mind, but I'm really excited about working in a county or city hospital, looking to provide services where they're needed most.

Topol: That's fantastic. I do want to get back to that idea of you writing a book. First, I think it's an incredibly important topic. Second, you are a fantastic writer.

What you packed into that essay—it's one page in the journal, but it's got so many critical thoughts. If you were to develop that further, with respect to that confidence gap in medicine, I believe it could be a great service to the profession. I know it can be daunting to think about. I never thought about writing a book until decades into my career. You've got the talent, the ideas, and the uniqueness of perspective. I know you don't have a lot of spare time, but I believe it would be great.

In the meantime, I am hoping this essay of yours really does get picked up by all the members of Medscape because it's a fantastic contribution. Thank you so much for taking the time to do it. I hope it doesn't stop there. I believe that you're onto something big—confidence in medicine. When I went to school back in the '70s, we were taught to be strong and know everything. Those attitudes have to shift and you really brought that out. We're indebted to you for your efforts.

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