Saturday, February 11, 2012

Is being an academic a disabilty (part 2)

The fancy term for knowing your own limits is "meta-cognition" -- that is, what you know ABOUT what you know.

According to Dror:

When it comes to experts, the following errors are common:

  • over self-confidence
  • do not listen
  • discourage, frown, and 'punish' disagreement
  • take undue risk
  • Escalate commitment when challenged
  • Wishful thinking
  • Confirmation bias  (search for and see supporting facts but not conflicting facts.)

Again,  these are all errors that all humans tend to make, but non-experts may be much more aware of their own tendency to make such errors,  and recover from them gracefully the next day.

Experts, on the other hand, have a much higher level of investment in their reputation,  and there is no natural internal limit to the justified self-confidence they have in one area that lets them know they have crossed outside the boundaries of what they know and what they only think they know.

Among nurses,  there are often comments about specific doctors who consider themselves only a short step below God,  whose egos are so large that "they come into the room before the person."

But that's anecdotal and just jealousy right?  Wrong. Let's find some objective data. I'm a private pilot and follow this sort of thing.

Example:    Doctors have the highest rate of small aircraft accidents after any other group or profession, except teenagers.

Crash Risk in General Aviation,   by Guohua Li, MD, Dr.PH and Susan Parker, MPH,
JAMA. Apn1 11,2007-Vol297, No. 14 p 5196-1598.  ( )
which also cites
Booze CF Jr. Epidemiologic investigation of occupation, age, and exposure in
aviation accidents. Aviat Space Environ Med. 1977;48:1081-1091.

I can't right off find the statistics for teenagers, but I do recall noting it as I read it a while ago.

Note -- I can't find such data adjusted for the fraction of flight-hours which are by doctors, to get the accident rate per hour flown by occupation.     It's possible that doctors, being wealthier than average, tend to own their own planes and fly more than the general public, which would bias those rates upwards.  On the other hand, it's doubtful that teenagers own their own planes at all, or that they fly very much,   and MD's are not known for having a great deal of free time for leisure activities.   So it's also possible that MD's actually both own their own planes but fly only infrequently, so the accident rate per hour flown is even higher for MD's than the statistics would imply.

A more likely explanation, in my mind,  is that MD's are significantly more unaware of the limits of their own expertise,  and therefore take more risks than other general aviation pilots.

While others may find the behavior described by "ego" or "arrogance", the point is that the doctors are, in fact,   somewhat crippled by the unintended and invisible-to-them side-effects of their own expertise.

We can talk more later about the behaviors which result from an effort to maintain their own self-image in the face of conflicting data.   What is expected, given narcissism in general, is that all errors and unexpected outcomes are automatically blamed on others, or events outside control,  anything except blaming them on oneself.    The emotions related to questioning ones own identity become so high that fits of rage are reported by surgeons, say, when anything goes wrong, including hurling instruments across the room and screaming at others present, etc.

This, in turn has two social side effects.

  • It reduces the probability that the MD will learn anything from the mistake.
  • It reduces the probability that anyone who associates with the MD will point out their mistakes in the future.
Thus begins a feed-back process which increasingly isolates the expert from realistic negative lessons from outside.

The result, getting back to the start of this post,  is that an expert with a huge investment in reputation, face, and accuracy becomes increasingly isolated from social interaction and particularly isolated from ability to allow personal errors and shortcomings to be visible in public.

It's certainly well known in the hospital I.T. department, for example, that it is extremely hard to get many doctors to learn new software if it requires that they have to go through the required awkward and fumbling state in public,  let alone in the presence of their peers.

In other words, my original comparison group, the "giggling gaggle of girls", has much more freedom to explore, make mistakes, ask questions of each other,  and figure out collectively and even enjoyable how new things works, and can acquire new skills together in a totally non-competitive way, helping each other learn.

Experts, on the other hand,  may suffer severe disabilities in their social ability to operate in such a learning group.   They have, effectively, a trained incapacity in this regard.

And, because they lack awareness of the limits of their knowledge, this incapacity extends far beyond the areas they would be expected to be experts within,  to all other kinds of interactions in life.

To some extent, all people and most higher animals are quite aware of "face" and try to no do things that would embarrass them in front of their peers.   I've certainly observed that among bird flocks, cats, and dogs, as well as humans.

Also, to a very large extent, what people are inwardly terrified of is being thrown out of "the flock",  of becoming unwanted, undesired, an "outsider", or one of the "them" category that disparaging describes those outside the in-crowd.

The result is that the LAST thing in the world people want is some sort of effort to surface, reveal, tell-all, and show errors and flaws.      This, of course, makes something like the Toyota "lean" process, or Six-Sigma,   which is precisely designed to surface such problems,   astoundingly difficult, if not impossible to implement for corporate change agents interested in rooting out and fixing these deeper, hidden problems.

So, again,  those experts who have fallen into this trap, perhaps through no fault of their own, get a triple dose of the deeper anxiety everyone feels about being "found out" to be "a fraud" or "less than one has pretending to be."

The result is to build higher and higher protective walls and shells around oneself, and to avoid, at all costs, situations in which one might accidentally slip and reveal some internal flaw.

These days, in the corporate world and in politics,  often it only takes a single mistake, a single comment uttered in an unguarded moment,  caught by an open microphone,  to end an entire career and flag someone as expelled from the "in group."

The result has to be an intense loneliness and constant state of both rage at the stupidity and errors of those around one, and fear that one's own flaws will become visible.

Again, it is not surprising that the drug-abuse and suicide rate among MD's is quite high.  They have become emotionally and socially crippled by external forces and training, and are in every sense of the word disabled, unable to participate in the normal social activities of daily living that many people take for granted.

It is not surprising in this context that the development of Hospital internal Electronic Medical Record systems is running a few decades behind other industries.    The talk is concern about patient privacy, but the actual far deeper concern is that, by capturing everything electronically, it will become far easier for mere mortals,  even administrators,  to mine the data and detect and reveal weaknesses and flaws.

Moreover, in the corporate world these days,   administrators and managers are often those who have mastered the art of taking credit for anything good that happens, and deflecting blame for anything bad that happens, while keeping the spotlight focused anywhere but on their own performance.  (I'm speaking as an MBA who taught MBA's here,  and has been "in the kitchen.")

So,  the largest threat to such administrators is the brightest MD's, who can see through puffery and see what is actually going on.   Given the politics then, it is precisely such MD's who present the greatest threat to the continued position of the administrators, and it precisely such MD's that said administrators constantly seek any bullets, or flaws, or errors to use to "take them down."

So MD's have the curse of training that emphasizes inhuman perfection,   the dangers of expertise in general,  attorneys ready to pounce on anything that even looks like a bad outcome regardless how correctly it was managed,  and a sociopolitical environment that is constantly threatening to expose and demolish their careers and lives.

One last curse of MD's, CEO's of large companies, and military officers is that they have to make rapid decisions based on insufficient information, with huge or fatal consequences if they guess wrong.    On the other hand, they have to make a STREAM of such decisions, one after the other, in an environment where "paralysis of analysis" is also a sin of omission that may have worse consequences than a "bad decision" that at least can be detected and reversed shortly.

Humans have finite capacity to worry about things, so these experts must take situations that are full of conflict and doubt and FORCE them into a state marked "decided, do not reopen or worry about this any more,  or you'll ruin all subsequent decisions."

They are forced to master the art of putting uncertain decisions out of sight, out of mind, and not constantly worrying about them and revisiting them, or they'll simply be overwhelmed and quite literally go crazy.

But this also means they have yet another source of blindness and resistance to the arrival of new, contradictory data, which calls their prior decision into question.

Enough on MD's for the moment.

In my next post I'll look at the problems of expertise in the Executive wing, among managers and CEOs.   Again,  we'll see that those people who the outside world thinks have the most power and privileges in the world are among the most limited and the most crippled in their capacity to function as a healthy human being and member of society.

(more in part 3)

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1 comment:

Sandra Thomas, MD, MS said...

Very insightful set of posts. Looking forward to the next installment.