🧭 REBEL Rundown
📌 Key Points
🧠 We don’t know what we don’t know: Low experience can inflate confidence; true expertise usually brings humble certainty.
🏥 ED relevance is universal: From central lines to transvenous pacing, over- or under-confidence shows up at every level—intern to seasoned attending.
🧩 Metacognition matters: Accurate self-assessment is a clinical skill; reflection + feedback loops keep us calibrated.
🛠️ Practice beats bravado: Skill decay is real; deliberate practice and HALO (high-acuity, low-occurrence) refreshers protect patients.
🤝 Psychological safety ≠ niceties: “Confident humility” enables questions, feedback, and better resuscitation decisions—especially under uncertainty.
📝 Introduction
Welcome to REBEL MIND—Mastering Internal Negativity during Difficulty. In this series, we turn the same critical lens REBEL EM uses for literature inward—into mindset, leadership, and psychological safety—so we can deliver better care outward to patients and teams.
In this episode and blog post, hosts Mark Ramzy and Kim Bambach (Assistant Professor of Emergency Medicine, The Ohio State University) explore a deceptively simple question: How accurately can we assess our own performance? The answer hinges on a classic cognitive bias that touches all of us in emergency medicine.
🧾 Paper
Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999 Dec;7 PMID: 10626367
Cognitive Question
How accurately can we assess our own performance?
💭 What is the Dunning-Kruger Effect?
The Dunning–Kruger Effect is a cognitive bias where:
Lower-skill individuals tend to overestimate their competence, and
Higher-skill individuals often underestimate theirs.
Translation for the busy clinician: early on the learning curve, confidence spikes (“Mount Stupid”) because we don’t yet see the complexity. As experience accrues, confidence dips (“Valley of Despair”) with growing awareness, then rises again—grounded in nuance and humility.
Key insight: True expertise ≠ louder certainty; it’s often quieter, more curious, and more collaborative.
How It Applies to the Emergency Department
Procedures (e.g., central lines, TVP): Watching a 5-minute video creates “I got this” energy—until the wire won’t pass, the patient thrashes, or you hit carotid. Competence includes troubleshooting in context.
Skill Decay is Inevitable: If you haven’t done a chest tube or a TVP in months, you’re not as sharp as last time. Without deliberate refreshers, you drift below the safe-performance line.
Everyone’s a Novice Somewhere: New disease entities, evolving algorithms, new tools (POCUS, decision support) mean even attendings routinely re-enter novice zones.
Feedback Blind Spots: Lower performers can both overestimate their skills and resist feedback—while many high performers (particularly women, per discussed literature) undervalue their abilities.
Culture is Clinical: The ED demands decisive action amid uncertainty. Psychological safety + confident humility lets teams surface alternative diagnoses, challenge momentum, and correct course fast.
⏩Immediate Action Steps for Your Next Shift
- Run a 60-second debrief on two cases
What went well? What would I do differently next time?
Write one improvement you’ll test today. - Play “What if the opposite were true?”
Anchored on “lumbosacral strain”, Ask, What if fever/incontinence appears? How does that change my path? - Solicit 360° micro-feedback
Ask a nurse, resident, and peer: “One thing I did well; one thing to improve.” Say “thank you,” not “but.” - Schedule a HALO refresher this week
Pick one high-acuity, low-occurrence procedure (TVP, cric, thoracotomy).
Do a 10-minute mental model + equipment walk-through; book sim time if available. - Adopt a pre-procedure pause
If X goes wrong, I’ll do Y.
Name two likely failure modes (e.g., “wire won’t advance,” “delirium/agitation”) and your first corrective step. - Language shift on shift
Swap “I’m sure” → “I’m reasonably confident, here’s my plan B.” Invite input: “What am I missing?”
Conclusion
The Dunning–Kruger Effect isn’t a moral failing; it’s a predictable human pattern that every clinician rides—often multiple times per day in the ED. The antidote is metacognition: routine reflection, explicit debiasing, deliberate practice, and feedback within a psychologically safe culture.
🚨 Clinical Bottom Line
Competence is quiet and curious. The more we know, the more we recognize what we don’t—and the better we become at caring for patients and each other.
Further Reading
- Dunning D, Kruger J. Unskilled and Unaware of It (1999). Classic paper introducing the effect.
- Croskerry P. Cognitive forcing strategies in clinical decision-making.
- Kahneman D. Thinking, Fast and Slow. Heuristics & biases in high-stakes decisions.
- Ericsson KA. Peak: Secrets from the New Science of Expertise. Deliberate practice & skill acquisition.
- Edmondson AC. The Fearless Organization. Psychological safety and learning culture in teams.
Meet the Authors
Mark Ramzy, DO
