In 1995, McArthur Wheeler walked into two Pittsburgh banks and robbed them in broad daylight with no visible attempts at disguise. He was arrested later that night, less than an hour after video tapes of him were taken from surveillance cameras were broadcast on the eleven o’clock news. When police later showed him the surveillance tapes Mr Wheeler stared incredulously “but I wore the juice” he mumbled. Apparently, Mr Wheeler was under the impression that rubbing ones face with lemon juice rendered it invisible to video tape cameras. (Fuocco 1996)
This unfortunate affair serves to illustrate an effect known as the Dunning-Kruger effect after two psychologists Justin Kruger and David Dunning from Cornell University published an article entitled “Unskilled and unaware of it – how difficulties in recognizing ones own incompetence can lead to inflated self assessments.” (Kruger 1999) (WIkipedia reference) The authors note that people tend to hold overly favourable views of their abilities and this over-estimation occurs in part because people who are unskilled in these domains suffer a dual burden – not only do they reach erroneous conclusions and make unfortunate choices but their incompetence does not allow them the cognitive ability to realize it.
Another way of thinking about this is that of insight. People who lack insight or understanding may then over-emphasize their own abilities. These concepts have been known for some time as Charles Darwin noted in 1871 “ignorance more frequently begets confidence than does knowledge”.
“It is one of the essential features of such incompetence that the person so afflicted is incapable of knowing that he is incompetent. To have such knowledge would be to remedy a good portion of the offence” (Miller 1993).
Whilst these concepts are self evident and known in many walks of life it is particularly pertinent to the field of surgery and in my own area even more so in the setting of difficult endometriosis surgery. I believe the problem has largely arisen because of the generally poor quality of excisional surgery around the globe. Many surgeons remain of the view that diathermy is adequate to deal with endometriosis whilst multiple studies have confirmed that excisional surgery is preferable. At its most difficult and severe stage, endometriosis can be exceedingly difficult to assess. In the setting of complete cul-de-sac obliteration with the bowel adherent to the posterior aspect of the uterus in the more severe forms the uterus may not even be able to be visible at laparoscopy because of these adhesions. The surgeon who only occasionally confronts such a case may not recognize what they are dealing with and is unlikely to have the necessary surgical skills to clear the disease and achieve an optimal result. Many surgeons who come to my theatre as visitors have never seen the types of dissection that are required to deal with the disease. In the absence of such knowledge or experience they may attempt to deal with the situation themselves with sub-optimal results and high rates of morbidity.
As most people would appreciate, the more you practice at a task the better you tend to become. For this reason in many fields of surgery, particularly areas such as cancer treatment, the general trend has been to move the treatment of these cases to specialized units where high volume surgical load is performed ultimately resulting in optimal outcomes and minimal complication rates. It is also noteworthy and obvious that a skill level in one area of surgery may not be applicable in another area. In most parts of the world surgery is now becoming a highly sub-specialized skill so that within the varying disciplines people will sub-specialize in a particular area, procedure or disease process. This has not traditionally been the case with obstetrics and gynaecology but I believe is increasingly likely to be so.
There is a flip side to the Dunning-Kruger effect involving the opposite end of the spectrum. Whilst at the bottom end the incompetent tend to over-estimate their skills and possibly operate when that would be inadvisable, the highly skilled who are deeply aware of the difficulties and problems particularly with severe cases of endometriosis may be inclined to be less aggressive even when they ought not.
Fuocco, MA (1996, March 21). Trial and error: They had larceny in their hearts, but little in their heads. Pittsburgh Post-Gazette, pD1.
Darwin, C. (1871). The descent of man. London: John Murray.
Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. Journal of personality and social psychology 1999; 77(6): 1121-34.
Miller, WI. (1993). Humiliation. Ithaca, NY: Cornell University Press