Experts
(and those who just think they are )
Used with Permission from Medical Laboratory Observer, September 2001
Copyright © 2001 by Nelson Publishing Inc.
http://www.mlo-online.com/I was recently in the home center to buy a mirror. I wanted to replace a broken pane on our bathroom mirror and I needed the piece cut to size. I asked the associate at the glass cutting station if he would cut the mirror for me but he refused, stating that the backing on the mirror would cause the mirror to shatter if we attempted such a cut. I didn't argue, but purchased the mirror and satisfactorily cut the mirror at home using a hand-held glass-knife and a straight edge. I chalked the experience up to another example of inadequate knowledge and poor service. It happens every day; someone thinks he knows something he doesn't know, and he confidently gives the wrong answer. This happens at work too.
At a recent Interdisciplinary Improvement meeting a physician representing the Internal Medicine service told this story:
"Saturday evening one of the medicine residents encountered a phlebotomist coming into a patient's room as he was leaving. The doctor had requested a CBC with Differential and asked the phlebotomist to make sure that the patient got a peripheral blood smear. The phlebotomist responded that a peripheral blood smear was not available until the next day because it was a 'sendout' and the 'sendout' office was closed. The doctor disputed but was somewhat dismissed. He ultimately phoned the lab and spoke with the supervisor to get his peripheral smear."
Our quality improvement team really liked this story which unfortunately is not isolated. We wanted to know how people can answer a question, even when they don't know the correct answer. We wanted to know if they think before they answer.
Thinking:
Dr. Jonathan Baron, a Professor of Psychology at the University of Pennsylvania, states that thinking begins with doubt, and without doubt there is no need to think. Dr. Baron says: "It begins with doubt. It involves a search directed at removing the doubt. Thinking is, in a way, like exploration."
The thinking exploration involves a search for possibilities, a search for evidence that will either strengthen or weaken the value of the different possibilities and a search of goals by which we evaluate the possibilities. A useful model might look like this: doubt leads to a search for possibilities and then a search for evidence to decide which possibility would help us reach the most desirable goal.
Could this help me at the home center?
Let's re-play the home center scenario with thinking involved. I ask the associate if he could cut the mirror, only this time he wonders if the mirror could be cut and finds two possibilities, maybe it could, maybe it could not. He next searches for evidence —perhaps he consults a more experienced associate. If the evidence is unfavorable, the process ends, but suppose the evidence is favorable. He will cut the mirror, right?
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Not so fast, let's look at the goals. There is the home center goal for customer satisfaction and repeat business. But there might some conflicting personal goal(s) to get to lunch on time or to avoid embarrassment because the associate is unfamiliar with the glass cutting station. The outcome of this play is not assured because the thinker's goals may conflict, even with correct and believable evidence.
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Ultimately, this thinker has to make a decision (choose the possibility) with the strongest believable evidence, in light of the strongest goal or motivation. I bought the mirror and cut it at home because I had evidence, from prior experience, that the mirror could be successfully cut and I had no conflicting goals. I needed to repair the mirror. |
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Dr. Baron describes the interplay of thought, which involves making decisions, forming beliefs and choosing goals within what he calls the search-inference framework. As in the above example, the thought process presents conflicts and dilemmas, and the bottom line remains, thinking is hard and not-thinking is easy.
Maybe doubt is the problem.
Because without doubt, we don't have to search for and weigh all of the possibilities, evidence and goals. But people who have no doubt still make errors and somehow these are the people who think that they are experts.
Overconfidence & people who think that they are experts:
There are numerous references describing the dangers of overconfidence in decision making and there are varied ways of describing overconfidence. Dr. Dietrich Dorner describes the Chernobyl disaster of 1986 as a textbook example of overconfidence leading to bad outcomes. Dorner describes a group of overconfident "expert operators" who had recently won a productivity award. When faced with a difficult time schedule they shortcut the safety rules (as was their habit) and directly caused the disaster. Dr. Dorner says that the disaster was no accident, because the operators did everything wrong on purpose.
Janay Kissinger explores overconfidence in the clinical setting and relates a simple definition in one nurse's observation that overconfidence is the feeling that "one is so sure of himself, that questions are no longer asked". Kissinger uses concept analysis to define the characteristics of overconfidence and draws heavily from the literature citing how experience leads to confidence (as well as overconfidence). She describes four factors (antecedents) that lead to overconfidence which include: large amounts of positive feedback, the reliance on unaided memory, the lack of awareness of outcomes and the failure to search for "disconfirming" evidence. This construct is consistent with the models of failure and "poor thinking" described by Drs. Dorner and Baron and helps us to understand how we fail.
(table)Conflicting goals:
In today's environment, we are asked to produce more of everything and to produce it faster. This pressure to produce, presents conflicts and unclear goals. In our management lectures to Allied Health students we introduce the students to the language that they will soon hear: working short, pulling a double, over budget, position freezes, is it ready yet?, can't you go faster?,... In the real world, the goal to go faster with fewer resources conflicts with the goal for high-quality, error-free performance.
The pressure of the workplace comes from the conflicting goals and under such pressure it is easy to lose sight of the outcome. In this environment, the temptation to take shortcuts is high 2.
Answering a question from the "expert memory" is a common practice and it seems more productive than looking for the correct answer from an external source. Psychologists describe the search for answers in memory as the availability heuristic, a type of shortcut that often results in "non-expert" performance 1. The wrong answer taken from memory alone, is fast to produce but is likely to produce a negative outcome.
What does this all mean to us?
Let's consider the phlebotomist, who knows that the peripheral blood smear is a "sendout". If a phlebotomist works for five years, he generates a good deal of valuable experience fed by generally positive feedback. One thing that phlebotomists do is to look up the names of unfamiliar tests in the computer in order to determine the collection instructions. Over time, the phlebotomist comes to know all of rules for collecting common tests. Somehow they also come to know that uncommon tests are sendouts and at some point they deem themselves "expert" so that they no longer need to look up information in the lab computer. To our "expert" phlebotomist, a peripheral blood smear, (an unfamiliar term) is a sendout test and the office is closed for the day.
If we doubt, we will search and if we focus on the patient outcome as the primary goal we will search and weigh evidence with vigor. The essence of proper thought is doubt and we should then search, with an eye on true goal. Genuine experts are rigorous in these habits and gain the full benefit of experience.
Last month we received a major complaint from a nursing unit. It seems that morning lab specimens were not collected on three different patients. One team member quickly diagnosed the problem as a "...computer interface failure. The computer people know about it and are working on a fix"— end of investigation. But another member did a full review of each complaint and as a result identified three distinct errors including an erroneously cancelled order, a failure to place the order and one computer interface failure. One member of our team is becoming a true expert.
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