Don't fall into the confidence interval.

How to feel good about your decisions when you don’t feel good about yourself.

(A longer version of this essay appeared on Doximity - https://www.doximity.com/doc_news/v2/entries/18293783)

“Seems diffident.”

Even though I wasn’t entirely sure what that word meant (which was also shame-

inducing), it burned. Hearing those words while sitting across from my residency program director

felt like an instant hot coal pressed into my chest. I associated the word with indifferent,

and the definition (when I looked it up) isn’t too far off from that:

Def: modest or shy because of a lack of self-confidence.

"a diffident youth"

Synonyms: shy, bashful, modest, self-effacing, unassuming, meek, unconfident,

unassertive, timid, timorous, humble, shrinking, reticent, hesitant, insecure, self-

doubting, doubtful, uncertain, unsure, self-conscious.

Throughout medical training we are evaluated. Every day. But the formal in person and

written evaluation that comes at the end of the rotation makes it final. You’ll either read

with happy pride their remarks about you (“an excellent resident”), or sit with a hot

burning shame. “Diffident’ might not seem to you like the worst thing to be called, but it

was close.

Perhaps lazy might have been the very worst thing to be called. But a lack of self-

confidence, hesitancy and uncertainty all came as a close second. After all, we

Pathologists are the consummate deciders. That one word felt like a 2-ton weight dropped

on my life.

So I did what I’ve always managed to do with crippling criticism. I let it destroy me for a

while, and fed into the same problematic traits. I resented the pathologist who said it.

‘Perhaps if he wasn’t such a jerk, I would have felt more comfortable’. I couldn’t look at

him and felt like the entire department was disappointed in me.

And then I faced it. The truth inside his evaluation.

I wasn’t confident. Sometimes, with the fire hydrant of information blasting me, I just

curled up. If I couldn’t tackle the topics completely and thoroughly, the way I knew the

material warranted, I felt paralyzed. When you're paralyzed during medical training and

don’t step up for tasks, you fail.

It makes sense that it’s not okay in any branch of medicine to demonstrate a lack of

confidence. (No one wants to give their surgeon a pep talk!) But training is the painful

nexus where you are relatively ignorant and still expected to perform as if you are not.

And Pathology is an area not known for good communicators. All the other residents in

my program seemed secure, knowledgeable and aloof. There was little chitchat that

wasn’t intended to one-up the other residents. When I think back on my training in

pathology, lonely is the word that comes to mind.

Pathology training really tests you. It’s a repeat of every topic from medical school

except more in depth and more complicated. We’d work from 7am to 6pm most days

with prep for conferences, talks and research as extra time. Coming in to review cases

over the weekend was celebrated and late nights were normal. All of this meant there was

no room to lick my wounds and retreat from the criticism.

Imagine my surprise then on a dermatopathology rotation when a consultant told me he

was uncertain. We were looking together at a difficult case when he said: “On 99 out of

100 days, I would call this a melanoma.”

He was talking about the statistical term the confidence interval. Per his shorthand

explanation, it means that if you repeat a situation 100 times, you may not get the exact

same result each time. He was expressing uncertainty! What I had spent my first 2 years

of training avoiding at all costs. But this was uncertainty that was expected and could be

accommodated. He could look at additional tests or share the case with other colleagues.

Just hearing him use this as a tool helped me take on a more effective and self-

compassionate approach to learning and practicing. The estimated confidence interval

became my own mental shortcut to frame my imperfect humanity. I became more open

to developing skills, not just trying to project confidence. I was there to learn pathology

and become the best pathologist I could be. Instead of looking for other's opinions, I

shifted to curiosity.

A quote from Brene Brown says it best: “Healthy striving is self-focused – How can I

improve? Perfectionism is other-focused – What will people think?”

When I was focused on minimizing other people’s judgments of me, I had little room left

over to grow. I wanted to meet my superior's expectations and I didn’t really care about

my true performance. That’s where the ‘diffidence’ crept in. Once I dropped that facade I could start actually learning for me. I didn't have to be a perfect or a superhuman resident.

This made it easier to learn and to accept feedback and criticism. The important things

were to keep working, keep striving and keep learning. I developed new coping skills and

new ways to make decisions and feel better about the decisions I did make.

We think we want 100% confidence to move forward in life. But within the range of

possible answers, there is some uncertainty. Learning this helped me continue to learn.

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Here are some of my hard-earned maxims for how to feel better about decisions:

• Get comfortable with being uncomfortable.

• Know you will not know everything - that is unrealistic and leads to paralysis.

• Cultivate real friends at least tangentially related to your field that you can relate to.

• Take heart - if you care enough to care, you’re likely to be on a better track. Burnout is not caring.

• Sometimes putting things on the back burner can help make things clearer.

• Use Occam’s Razor - when all else equal, the simpler explanation is more likely.