Confidence

Confidence by Ash B. Alpert and Bahar Moftakhar. Read by Maggie Sheridan. Two fellows explore the feedback they received during training to develop confidence, or to appear confident.

TRANSCRIPT

SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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LIDIA SCHAPIRA: Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org.

SPEAKER 2: It was my first day as the hematology-oncology fellow on the inpatient leukemia service. I introduced myself to the team of residents and nurse practitioners who had spent the last month circling the sixth floor of the cancer center. The residents were nearing the end of their month-long rotation, and their faces reflected the sheer number of hours they had spent rounding, writing notes, and caring for their patients. They exchanged silly stories about their patients in hushed tones as if they were talking about peculiar relatives.

The senior resident filled me in on their daily routine. "Now's your chance to grab coffee," she whispered to me like it was a secret. "We kind of just wait here until the attending is ready to round."

As if cued, the attending appeared. The team created a semicircle around him. It was unspoken, but he was our leader. I awkwardly tried to figure out where to stand. I was told I was there to learn, but I was also supposed to lead. We spent the morning walking around the unit, and the residents and nurse practitioners took turns presenting their patients. The resident recited his presentation, detailing overnight events, sharing social history, and listing each abnormal lab. "Calcium was 10.3. Glucose was 123."

I felt myself start to cringe, realizing how long rounds were going to take, but I remembered being in his shoes just years before and began to encouragingly nod along. He methodically reviewed each organ system, allotting the same attention to the normal blood sugar as the rising lactate dehydrogenase.

I became aware that the team was looking at me as they presented. I nodded along as they spoke, jotting down notes to ask at the end of their presentation.

The next presentation had only just begun when the attending cleared his throat to chime in. "Did the patient get platelets overnight? Did you notice the elevated uric acid? What day of the cycle are they on?" he said in one breath.

I am sure they were getting to that, I thought to myself. The attending took over as I withdrew, and I noticed the team shift to him. It seemed as though the attending was thinking, "Let me just do this myself."

The morning bled into the afternoon, and eventually, the carousel came to a halt. The team scattered to complete their task for the day, and it was just the attending and me left standing. He smiled at me. "Should we go to the ED and see the new patient?"

The long walk to the emergency department was spent making small talk. He asked me about my family. I asked him about his. He asked about my interests. I asked him about why he became a cancer doctor. I began to feel at ease, although I could not stop thinking about how I felt so small compared with him just moments before. But now, I was an equal.

We claimed a computer in the ED workspace and spoke in raised voices above the chaos and chatter. I told him everything I had read about the new patient-- a young woman who had come in overnight for progressively worsening fatigue, weakness, and dyspnea on exertion the last several weeks. She was found to have significant pancytopenia.

Her case that intrigued me. The patient was my age, and for that reason alone, I already felt bonded to her. The attending scrolled swiftly through her labs, my eyes darting up and down the screen trying to keep up. She was hemolyzing. But why? My eye caught her negative DAT. "We should screen her for PNH," I said, pointing at the screen. I remembered seeing a similar case months ago. The scrolling stopped. "That is a great idea," my attending said. I began to relax.

As we were wrapping up, I asked how I could be the most helpful during our week together. "You remind me of myself," he said to me. "I think you should be more confident. I know you have good ideas, but I want you to speak up."

Confidence-- I nodded. I knew what he was trying to say. I was not loud. I was not the biggest personality in the room. I was not foreboding or scary.

I met my co-fellow that evening for dinner. We debriefed the week over small plates of Ethiopian food. We talked about the word "confidence," and they told me their own story as follows.

When I was called about a young patient with lymphadenopathy and splenomegaly, I was between one floor and another, trying to get back to my team on the ED. I had worked through lunch while we had spent the last few hours in the belly of the hospital, seeing patients while I continued to get phone calls about others. I figured I would take this patient. It was my turn to see a new consult, and anyway, evaluating patients for lymphoma was something I did frequently in the clinic.

The resident who called told me that the patient was admitted with aphasia and left-hand weakness. She had a hemoglobin level of 4 grams per deciliter and a creatinine level of 6 milligrams per deciliter. Head computed tomography had demonstrated a right frontal lesion that did not properly explain the clinical presentation. By the time I was called, the neurologic symptoms had resolved.

When I went to see the patient, she was curled up and holding the side of her face. She was thin and pale, beautiful, and clearly uncomfortable. Her sister told me the story, which included back pain, fevers, weight loss, and fatigue. The patient had started taking massive amounts of ibuprofen and stopped leaving the house. When I asked the patient what was bothering her the most, she told me it was the headache, and she seemed to have trouble keeping her eyes open, so I offered to turn off the light.

After I left, I found my attending and one of the residents in a corner of the ED. The attending was sitting at a computer, reviewing the patient's chart. "Simple," he said, describing the case. He held a pencil. I started to tell my attending what had happened in June, and he interrupted. "What did she come in for? What were her labs?"

I was having trouble stringing my thoughts and the story together. I felt dizzy with hunger, sleep deprivation, the attention of the resident, and my attending's rapid-fire questions. "I need a history," the attending said. "Exam? Assessment? Plan? What's the differential for her anemia?" I did not speak. "Reactive or malignant? What tests do you need?"

The resident suggested an SPEP. "Do you agree?" the attending asked me. I shook my head. "No." It didn't fit with her headaches, the neurologic findings. "Back pain, renal failure, constitutional symptoms-- you have to think about myeloma," the attending said, putting down his pencil. I felt hot shame.

The next morning, the resident on the primary service paged me to tell me that the patient was going into the intensive care unit. She'd had a seizure. One of the residents pulled up her imaging, and we saw a bleed that had bloomed in her brain. I woke up in the middle of the night thinking about her, imagining the blood in my own brain, a feeling like wetness. She was two years my junior, 42 years old.

The next day, when I opened the patient's chart, I found she had died overnight. There was not a death note, just vital signs that trailed off. That day, my attending gave me feedback. "You're good," he said. "You just need to have more confidence. You learn the most from putting your ideas out. If you're wrong, then you will learn."

I nodded, but I was thinking about the culture of medicine, the way he forged ahead with his differential and missed the diagnosis-- endocarditis with bleeding septic emboli. I was also thinking about the other times I had heard this feedback. In residency, my intensive care unit attending had told me to be more confident and suggested I be more like one of the male residents, who was loud, brash, and arrogant.

I had not wanted to be like that resident, and I did not want to be like my hematology attending. His confidence had translated to rudeness and allowed the diagnosis to elude his grasp. His feedback had left me without steps I could take to avoid the missed diagnoses in the future.

I would have liked to review the case with him, working through it to figure out where we had gone wrong. Perhaps I had also been hoping for an apology for the way he had acted toward me or remorse about the case, which I did not get.

I called my friend Bahar the day my patient died. I expressed my deep sorrow for our patient, for our inability to help her, and my anger at my attending. She listened intently and expressed her empathy and her caring. She carved out room for my grief, my real self, and an alternative to business as usual in medicine.

Oxford dictionaries define confidence as "the feeling or belief that one can rely on someone or something, firm trust, as in, 'We had every confidence in X,' the state of feeling certain about the truth of something, or a feeling of self-assurance arising from one's appreciation of one's own abilities or qualities."

However, feedback to be more confident from male physicians to those of us who are not men conveys more than what is explicitly included in this dictionary definition. In the commentary that follows, we share our concerns with this feedback to female, transgender, and/or nonbinary trainees and provide our own suggestions about transformative feedback that makes room for all of us in medicine.

In 2013, Sheryl Sandberg wrote a book called Lean In, which was marketed as a feminist manifesto and provided women with tips to succeed in a male-dominated business world. More recently, the book has weathered considerable criticism for advising women that they will succeed if they simply get out of their own way and work hard. The critiques suggest the Lean In strategy "hands a rubber ducky to someone hit by a tsunami and then inadvertently encourages us to internalize our own discrimination, leading us to blame ourselves."

Providing women, transgender, and nonbinary medical trainees the advice to be more confident has similar drawbacks. This feedback suggests that we would be more successful if we simply stop doubting ourselves. This message makes invisible the structural inequalities in medical training-- the barriers we as marginalized people face in accessing training and the micro- and macroaggressions we face along the way.

For those of us who have been marginalized, those of us who are people of color, people with varying abilities, transgender, women, and/or queer, being asked to be confident is like asking us to step into a store where we have been accused of stealing and act like we own it. This advice puts the responsibility on those who have been harmed to engender respect. Telling us to be confident also suggests assimilation into a hierarchical culture instead of changing that culture to be more just.

Espousing confidence as a vital quality among physicians and trainees has additional drawbacks. Confidence supports the enterprise of medicine and promotes the status quo. If physicians act self-assured, perhaps our actions, individually and collectively, will not be questioned. Confidence provides us with a means to avoid considering the ever-present possibility of error that we will cause harm.

In this way, espousing confidence may make us overlook varying viewpoints and perspectives and block potentially transformative changes that could make medicine a more healing practice. In fact, confidence may reinforce hierarchy. If those of us who can access self-assurance espouse it without thinking, we may reinforce power imbalances between colleagues or patients and physicians.

Confidence relies, in part, on pattern recognition-- for the problems people are presenting with to fit into simple, definable entities. Our patients who have concerns or symptoms that do not fit into a usual pattern may be dismissed or shuttled into a category that does not quite fit. These missed or incorrect diagnoses may lead to considerable harm.

Additionally, confidence may not leave enough room for uncertainty, and much that is beautiful in medicine is uncertain and/or could not be immediately known to us-- how a specific patient will feel at a particular time, how a particular patient will do with a given treatment, and when a particular patient will die. If we as physicians do not leave room for our own uncertainty, how will we be able to be present with patients' uncertainty about the next best treatment decision or about their futures?

Feedback is at the heart of apprenticeship and provides a formal mechanism by which trainees can reflect on their own progress and have tools with which to grow. Feedback should be nonjudgmental and kind. Moreover, feedback should be specific to the trainee and about their observable behaviors. Feedback could offer trainees suggestions on improving clinical problem-solving, empathetic and patient-centered care, and/or working with a team.

Ideally, feedback would be bidirectional, thus also providing input to established physicians and creating non-hierarchical care-- ugh. Ideally, feedback would be bidirectional, thus also providing input to established physicians and creating non-hierarchical-- hierarchical-- ideally, feedback would be bidirectional, thus also providing input to established physicians and creating non-hierarchical care teams that support all members.

Trainees, who often reflect more diverse identities than their attendings, could offer feedback on providing patient-centered and non-paternalistic care and cultural humility. In this way, feedback could be a mechanism not just for the growth of individual physicians but for the transformation of medical systems. This may be the only path forward to creating medical training and medical care that is truly inclusive and supportive of all of us.

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LIDIA SCHAPIRA: Welcome to The Art of Oncology podcast. With me today are Dr. Bahar Moftakhar and Dr. Ash Alpert. Welcome to both of you.

ASH ALPERT: Thank you. It's good to be here.

LIDIA SCHAPIRA: It is unusual for us to have an essay submitted by two authors. So I would love for you to tell the listeners a little bit about what led to this writing collaboration and what the experience was like for you.

ASH ALPERT: Bahar and I were just actually talking about that then-- I don't know, maybe one or two years since we first had the conversation that led to this paper. And we just decided to go out to dinner, and she told me this story that she related in the first part of the essay.

I think that sometimes you don't see something clearly until somebody you love has an experience you can relate to. But it was so clear to me, listening to the story she told me, that the feedback that she was getting to be more confident in a clinical setting sounded like misogyny and sexism more than anything else to me.

And strangely, maybe a few weeks to a month later, I had a really distressing experience with a patient, and when I tried to debrief with my attending, he gave me the same feedback. And so at that point, we started talking about collaboratively writing about what does it mean to be told to be more confident and trying to unpack our experiences in medicine through that one.

BAHAR MOFTAKHAR: Yeah, I agree with Ash. I think, as the readers will see, this piece revolves around a similar experience we had in which we were told by a superior that we need to be more confident. And I remember after my experience, when I was reflecting on that day, I was aware of how mundane that day seemed, and in fact, the feedback of being-- be more confident seems like such a benign comment. But I couldn't really understand why that feedback packed such a punch to me.

And when I spoke to Ash about it, and later, when they shared a similar story that they had experienced, it really made us want to unpack that feedback and understand why the word "confidence" resonated with us so much.

It was-- I very much enjoyed collaborating with Ash on this piece. I don't have any formal creative writing training, and my writing has always been deeply personal and for myself. So I looked a lot to Ash for their guidance and their input through this process.

So first, it was nice to be able to share this vulnerable moment with someone and then also going through the challenge of making sure both of our viewpoints were heard and then working on the revisions, and that whole process was extremely rewarding, and I very much enjoyed working with Ash.

LIDIA SCHAPIRA: So let's talk a little bit about the conversation and the writing and how it helped you to process what sounds like an important formative experience, where it could be that you could have done this over some feelings you had about a patient. But in this particular case, what both of you are really talking about is the experience of being a trainee in a highly pressured setting, right? So talk a little bit about the writing itself and the process of getting from these experiences and thoughts to an actual essay that you can now share with other readers.

ASH ALPERT: Actually, I think that a very important moment for me in the process of writing and editing this paper was meeting with you, Lidia, and hearing you say something about having had a similar experience. And during that conversation, I remembered that when I was an attending before I went to fellowship and I often used my first name with patients, that one of the advanced practice providers that I worked with told me that I should stop doing that because men are always-- are often referred to by Dr. So-and-so, and women, which I identified with at that time, are referred to by their first name.

And I remember thinking and telling that person that I do not have interest in being more similar to men attendings than I already am. And I think that came up in the conversation that the three of us had about this [INAUDIBLE] and really helped me to identify and unpack what it-- one of the aspects of what was going on, which was that in my way of being in medicine and in my way of thinking about medicine, perhaps I was [INAUDIBLE] some of the ways that hierarchy was manifesting itself. And when I got the feedback to be more confident, I felt that I was being told to try harder at a system that wasn't working for me.

And I think that for those of us who don't find that we're heard or seen in medicine or other spaces in our lives, we feel that the answer is to try harder, to speak louder, really makes invisible those experiences and also creates an impossible path.

BAHAR MOFTAKHAR: Yeah, I think this piece was important to share because it will resonate with a lot of trainees, especially certain groups of trainees who aren't able to harness confidence readily for whatever reason that may be. And I think it will also resonate with our mentors and teachers who provide feedback to trainees because it highlights the importance of giving quality feedback that's something that's tangible and actionable.

I don't know about Ash, but as we were writing this piece, I think one of the challenges was really dissecting what confidence is. Is this different from being overconfident? Are the pitfalls of confidence one that transitions into arrogance? And I think that we tend to perceive the person who's the loudest in the room or the biggest presence, the first to speak, the person who's interrupting or interjecting as the person who's most confident. And by virtue of how we define confidence, we tend to think that person is always right and has the answers.

And I think that we forget that these qualities come more naturally to certain groups of people, and in medicine, that's historically men and particularly white men. And I don't see confidence as something that you can just switch on or off, which is implied by the feedback of "be more confident." I think that we can change our behaviors to appear more confident for a period of time, but that assumes that those of us who are marginalized are holding ourselves back and really ignores the systemic issues that are in medicine for these marginalized groups of people.

LIDIA SCHAPIRA: So let's talk a little bit about how to make medical training or oncology fellowship safe, a place really of growth and recognizing that the work that we do and that we ask you to do all the time is really very difficult, emotionally charged, and you're working at a very fast clip and under a lot of pressure. So as you imagine yourselves now transitioning to being attendings, tell our listeners a little bit or one or two things that you'd be sure to do to create those kinds of safe learning environments.

BAHAR MOFTAKHAR: I think that there really needs to be just an open dialogue and space for everyone's thoughts and ideas to be heard. I think in the hierarchical medical culture it can be a really dangerous thing. Early in our medical training, we adopt this hierarchical thought process every step of the way. And when you're someone who's marginalized, advancing in this hierarchy is pretty challenging, and it's due to barriers we either put on ourselves or institutional barriers. And then this perpetuates what hierarchy looks like and then muffles the voices of those people who have different experiences or viewpoints.

And so people who are lower on the hierarchy, whether that's a medical student or a resident or fellow, feel uncomfortable speaking up or voicing their suggestions or concerns. And then this lack of diversity of perspectives then has consequences on patient care.

So I don't know what the solution for change is, but like I said, I think it starts with open dialogue, education for everyone at every level, and hopefully, this can create a safe environment. And as Ash and I are coming to the conclusion of our training and, in a sense, moving up this hierarchy, I hope we remember this and continue to create space for everyone.

LIDIA SCHAPIRA: So before we go to Ash, let me ask you a follow-up question. Imagine yourself now a few months down the road. You are the attending coming in to meet your team. How do you greet your team?

BAHAR MOFTAKHAR: I would introduce myself as Bahar, and I think I would remind whoever is on the team that I was there where-- whatever level of trainees I have with me that I was there in their shoes. And I would let each of those trainees introduce themselves and be heard and ask them like you did, Lidia, before we started the interview what-- how they want me to address them and things like that. Though I think it starts with grace and kindness, it's such a simple thing, but I think that's really the foundation of how we can change the medical culture.

LIDIA SCHAPIRA: So a moment of empathic connection, right? And you seem to me to be anti-hierarchical.

BAHAR MOFTAKHAR: Absolutely.

LIDIA SCHAPIRA: I look forward to having another conversation with you in a few years and ask how it's going. So let me ask Ash the same difficult question. You're now leading a team. How did this go for you?

ASH ALPERT: Yeah, so I think taking a step back even, I mean, I wonder how the system could change overall such that the structure of leading a team maybe didn't exist in the same way, because I feel like once I'm already leading the team, I'm in a position where it becomes really hard to connect with the other people on the team in a real, authentic, and safe way because the hierarchy itself isn't particularly safe.

So I wonder if there is a way going forward to re-imagine medical system in a way that could really provide an opportunity to decrease disparities, make them safe for trainees and everyone else, and the patients as well. I think that we probably need to think about the ways that we're using the labor of [INAUDIBLE] as well and how that impacts emotional and physical wellness. And there may be many other steps that we need to take to create spaces that really make room for everybody in a safe way.

LIDIA SCHAPIRA: So Ash, let me follow up with another question for you, and that goes back to the theme of your essay and what brought us together, which is confidence, right? So you talk a lot about the appearance of confidence in the eyes of others and not relating to that. What is confidence for you now? And how do you think about it, or do you even think about it?

ASH ALPERT: Yeah, so I guess what I started to realize as I was writing the paper that maybe the question of confidence is just the wrong question. And that it becomes a surrogate for telling people that they're the problem, as opposed to the system being the problem. So I think confidence can be a surrogate for being able to succeed in capitalism, for example. And so I've stopped thinking about it as a goal that I want to attain, but thinking about it more in terms of what are the implicit messages and how can they be made explicit and then shifted.

LIDIA SCHAPIRA: So a question for each one of you is this, what would be the top values in a system that delivers patient care and trains the new generation of specialists or physicians? What kinds of values would you hold high?

BAHAR MOFTAKHAR: I think that rather than there being an emphasis on confidence and this self-assurance trait, that I would say should be valued is self-awareness. I think someone who knows their limitations, who knows when they don't know the answer, who knows when someone else probably knows the answer better than they do, who knows that they don't have specific interactions with different groups of people and who wants to learn, I think that is a trait that's very valuable in the medical culture. And I think that for someone to allow uncertainty in their practice is such a beautiful thing, and that's something that I think we should appreciate.

LIDIA SCHAPIRA: So I'm hearing, in addition to self-awareness, a little humility and curiosity.

BAHAR MOFTAKHAR: Yes.

LIDIA SCHAPIRA: All right, let's turn it over to Ash.

ASH ALPERT: I think actually that sums it up pretty well. I mean, I was thinking of things like patient-centeredness, cultural humility, humility in general, willingness to ask deep questions. But honestly, I think that those three things would really be the basis of very high quality care.

LIDIA SCHAPIRA: Do you think that the experiences you had that inspired you to think about this are pretty universally shared by other trainees? Can you stay a little more about that?

ASH ALPERT: Interestingly, one of my attendings who knows about the piece told me that he was interested because he hadn't had this experience. So he asked his wife and daughter if they had experiences like this, and they both said yes. And it was a surprise to him, but maybe a good way for him to connect with other people in his life. And I definitely have heard this experience from many, many people who are not men in particular.

BAHAR MOFTAKHAR: Yeah, I agree. I shared this experience with my younger sister who's in medical school right now. And I think she was telling me that even early on in the medical training that she's had experiences like this. And for me, my experience with confidence through my medical training rose early on like her.

And my personal experiences are heavily tied to gender and I think that these moments appear subtle. In medical school on clinical rotations, it would be when a male colleague would speak over me. And in residency, it would be when the patient directs their questions to the male medical student. And I think we see those qualities and behaviors that we classically associate with confidence continually being rewarded. So these tiny moments of microaggression tend to add up and contribute to how you feel about yourself.

So when we hear feedback about being more confident with no further elaboration on how to do that, it tells us that we need to change your behaviors and act in a certain way. And it really discounts the work that we do and the knowledge that we have and patient care that we deliver. So it kind of makes us feel uncomfortable. So I think, like Ash was saying, there are certain groups of people who have had similar experiences like we've described in this piece.

LIDIA SCHAPIRA: I wonder just seen through the sexism lens-- and there are many other ways to look at this, of course, and we barely skim the surface of this in our conversation-- I wonder if you asked all of your female attendings if they've experienced similar moments. And my hunch is everybody will say they have.

And I think that different words have been used through the ages-- assertiveness, aggressiveness, and now we're down to confidence, which seems a little blander. But as you say, it really camouflages a much deeper sexist message, which is more, I think, be like me, be like us, right? I mean at least that's what I have taken away from this. And you're nodding, but our listeners can't see the nods. So I'm going to ask you to just say a few words. I'll let you finish with a message, again, that hopefully will inspire those who are listening to the podcast.

ASH ALPERT: So in some ways, it seems like an invitation to assimilate and leave other people behind. And I wonder if instead we could do the hard work of looking at our medical systems and figuring out how we can get them to really make space for our patients and make space for each other.

LIDIA SCHAPIRA: Bahar, do you want to say a few final words for our listeners?

BAHAR MOFTAKHAR: This piece, like you said, this word confidence seems like such a mild, bland, benign term. But for me, I was so surprised the emotion it evoked in me when I first heard it. And I think there are many layers to this. One is that being told to be more confident insinuates that there-- implies that there are these certain characteristics that we should embody and that's how we can get ahead. And those are certain characteristics that don't come naturally to some people.

And I think that confidence as feedback is very challenging because it's hard for someone to understand what to do with that feedback. Is this a reflection of my medical knowledge? Is this a reflection of my patient care? So I think the other takeaway I would take from our piece is really looking at how to give feedback and receive feedback.

LIDIA SCHAPIRA: Bahar and Ash, I really want to thank you for submitting your piece, for bringing this very important conversation to the attention of the readers of JCO. And I look forward to continuing our conversation perhaps in person, if that ever happens again. And again, thank you very much for submitting your essay and I hope all goes well.

Until next time, thank you for listening to this JCO's Cancer Stories, The Art of Oncology Podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories, The Art of Oncology Podcast is just one of ASCO's many podcasts. You can find all of the shows at podcast.ASCO.org.

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