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The Eight Levels of Ignorance about Patient Trust or “Amanah”: Why Medics with Smart Phones may be Guilty of the Dunning-Kruger effect without realising it

CharlesDarwinmanyyearsagosaidwisely:“Ignorance more frequently begets confidencethan does knowledge.” He would have notanticipatedhowahomosapiens in the21st and22nd centurymight attain information and useit for the good or bad ofmankind in this “newworld”. One has a feeling of pseudo-securitywith the knowledge of Rhoton’s NeuroanatomyandtheFunctionalAtlasofthecortexofthebrainof Duffau with Nowinski’s Brain coordinatessafely stored in a smart phone which at amoment’s notice could be used to show theyoungneurosurgicalinternoraveryexperiencedprofessor which functional neuroanatomy,neurophysiology, and cognitive neuroimagingcouldsavethepatient’slife. Amanah is defined by Dewan Bahasa danPustaka (1) as fulfilling or upholding trustsand moral responsibility. Ignorance and trustto do the right thing with the correct learned,memorised and understood tasks as mentionedbyProfessorEmeritiusEnkinMW,MD,FRCS(C)of the McMaster University Hamilton, Ontario,Canada (2) can be associated directly with theDunning-Kruger effect (3–5) that states thatin any given area of life, “under-skilled” and“undereducated people” suffer from an artificialarrogance borne of their ignorance of all they

Editorial

cannot do or do not know. Because they areunaware of their shortcomings, they develop acognitive bias, leading them to a belief in theirown competence or even superiority where theopposite should exist. Thus, this cognitive biasleads to a pseudo-security feeling. Ignoranceis truly bliss for that medical practitioner butabsolutelydangerousto thepatient! Incontrast,those senior physicians and surgeons who are,in fact, “skilled and educated” often suffer fromafeelingofinferiority(3–6).Weassumethatourabilitiesaremerelyaveragebecauseourmindsarefocusedoneverythingthatwehaveleft to learn.Themoreweknow,themoreweknowhowmuchwedonotknow.Forthisreason,Ihavelivedmywholelifewiththe4W,1Hconcept(what,where,why,whenandhow). As Enkin MW (2), highlighted, sharingignorance is much more difficult than sharingknowledgebut isperhaps evenmore important.Ourmoderntechnology,especiallymobilesmartphones, that can recall instantly informationfrom all over the world in any format and anylanguage imaginable translated automaticallymakes it easy for medics not to learn andmemorise information, which makes us “lazy”.Wedonotcaretolearnandmemorisebecausewehave tremendous amounts of information easilyavailable. AsEnkinMW(2)stated,“Weknowwhattodowith;wedon’tknowwhattobelieve;whattoassimilate;whattoignore;howtointerpret;andthe informationkeepspouring into thepetabytestorage capabilities of the clouds system”.Thus,

The Eight Stages of Trust and “Amanah” in Medicine and the Dunning-Kruger effect

Jafri Malin AbdullAh

Chief Editor, Malaysian Journal of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia

1Malays J Med Sci. Jul-Aug 2014; 21(4): 1-3

Abstract TheDunning–Krugereffectisacognitivebiasinwhichunskilledpeoplemakepoordecisionsand reach erroneous conclusions, but their incompetence denies them themetacognitive abilitytorecognisetheirmistakes.Theseunskilledpeoplethereforesufferfromillusorysuperiority,ratingtheirabilityasaboveaverage,muchhigherthanitactuallyis,whilethehighlyskilledunderratetheirownabilities,sufferingfromillusoryinferiority.

Keywords: physician, medical, ethics, Malaysia, education, neurosurgery

Submitted:21Apr2014Accepted:1May2014

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Malays J Med Sci. Jul-Aug 2014; 21(4): 1-3

Ihavemodifiedmyamanah to include8stagesofignoranceandlackoftrust(amanah)toimprovemedics’thinking(7). First Stage: the age of naivety and lack ofamanah(needstobeinculcated).Youknowyoudonotknow.However,youaresureyoucanlearn.Withthismethod,youwillcarryouttheamanahoflearning,memorisingandunderstanding(2). SecondStage:TheFacts.Youknowyoustilldo not know. Facts are facts. The facts are notignoredbecauseexamquestionsaretheretotestus.Ifwefail,wedonotearndegrees.Ifwepass,we move forward. Having amanah means thatwecontinuouslylearn,memoriseandunderstandbecausewewouldforgetwhatislearnedoverthenextfewweeks(2). ThirdStage:Naïveté.Youknowwhattodo.However, you do not know how to do it. Youramanahpushesyoutorelearn,rememorise,andreunderstand even with the help of the smartphone(2). FourthStage:Frustration.Youknowyoudonotknow.However,youknowthatothersknow.Amanah asksyou topracticeand teachskills toyourselfandotherssothatyoudonotforget(2). FifthStage:Expertise,thedangerstage.Youthink that you know, and others think that youknow.Amanahremindsourconsciencetospeakthetruthtoourpatientsandtoknowwhatwearedoingprior to treatmentandhazardoussurgicalprocedures(2). SixthStage:Pyrrhicsuccess.Youknowthatyoudonotknow.However,othersthinkthatyouknow.ExperiencedseniorspecialistsorAssociateprofessorsuseonlyskillslearnedfromexperienceand prior learned, memorised and understoodconcepts to treat disease processes. Amanahdictatesthatthepatienttruststhephysicianorthesurgeontobe‘skilled’intheprocedurethatheisperforming(2). SeventhStage:Ignorance.Youknowthatyoudonotknow;othersknowthatyoudonotknow;and it doesn’t matter. As the medical personbecomesa seniorconsultant, theexperienceshegained fromdifferent cases creates hismethodsandapproachestosurgeryandtreatment.Amanahisunheededanddeclinesasexperienceputs thehumanbrainat‘rest’.Heorshethinksthatheorsheknowseverythingfromexperience.Therefore,relearning, memorising and reunderstandingpatient anatomy, physiology and functionalcognitionisunimportant(2). Eighth Stage: Loss of insight. The personconcerned is the reference person or betterknown as the super consultant. Books, journalsand evidence-based management is neglected,

and special cases that are difficult to managearereferredfor“super”expertopinion.Deathatthe hands or mind of the surgeon or physicianis accepted as the final choice. The patient andpatient’sfamilyhascompletetrustinthesurgeonor physician (a functionalMRI shows that thetrustareainthebrainisintheangulargyrus(AG),anteriorcingulate(AC),leftfrontallobe(LF),rightfrontal lobe(RF),andputamen/caudatenucleus(PU/CA).Itissoreliablethateventhethoughtofthetreatingmedicbeingignorantbyapatientisdeemedimpossible)(8). There is so much knowledge out there,and we have to learn it. Trust must overcome

Figure 1: These people have constantlyinfluenced my decisions andcontributed to the way I learnedand thereafter envisioned theeight stages of trust and amanahin medicine. From the top mymother, Norleni Mohd Salleh,my father Leftenan General(Retired)Dato’AbdullahSamsudin,my neurology, neurosurgery &neuroscience teachers: ProfessorEmeritus Dr Luc Calliauw,Professor Dr Jacques Caemaert,Professor Dr Jacques de Reukfrom the University of Ghent,Belgium, and Professor EmeritiusDr Bjorn Meyerson from theKarolinska Institute, Stockholm,Sweden.

Editorial |TheDunning–Krugereffect

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ignorance. An alumnus of the University ofGhent graduating class of 1994/1995 suggeststhatthemoreexperiencedwebecome,themoretransdisciplinaryweshouldbecomeinourwayofthinking(Figure1). Remember, handphones never have aneternal running battery.When the battery runsout,doesourlearningend?

Correspondence

ProfessorJafriMalinAbdullahMD,PhD,FRCS(Ed),FACS,DSCN(Belgium)ChiefEditorMalaysianJournalofMedicalSciencesUniversitiSainsMalaysiaHealthCampus16150KubangKerianKelantan,MalaysiaTel:+609-7676972Fax:+609-7672359Email:mjms.usm@gmail.com

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2. Enkin MW. The Seven stages of Ignorance. In:Enkin MW, editor. BIRTH. [Place of publicationunknown]:WileyPeriodocals,Inc;2008.p.169–170.doi:10.1111/j.1523-536X.2008.00248.x.

3. Tan LT. Innovations in continuing professionaldevelopment--counteringtheDunning-Krugereffect.Clin Oncol (R Coll Radiol). 2011;23(10):659–661.doi:10.1016/j.clon.2011.08.010.

4. DunningD, JohnsonK,Ehrlinger J,Kruger J.WhyPeople Fail to Recognize Their Own Incompetence.Am Psychol Soc. 2003;12(3):83–89.

5. Ehrlinger J, Dunning D. How chronic self-viewsinfluence (and potentially mislead) estimates ofperformance.J Pers Soc Psychol.2003;84(1):5–17.

6. Kruger J, Dunning D. Unskilled and unawareof it: How difficulties in recognizing one’s ownincompetence lead to inflated self assessments. J Pers Soc Psychol.1999;77(6):1121–1134.

7. Falchikov N, Goldfinch. Student selfassessment inhigher education: A meta-analysis. Rev Educ Res. 1989;59(4):395–430.

8. WatabeM, BanH, YamamotoH. Judgments aboutothers’trustworthiness:AnfMRIstudy.Hum Behav Evolution Soc Japan. 2011;2(2):28–32.doi:10.5178/lebs.2011.16.