A question of confidence

7 minute read

Lucky earrings were not enough to take me from simply existing to successfully thriving. It’s time I started to believe in myself.

In the past fortnight, “confidence” has been a topic of discussion for me at three dinners, two brunches and about 10 phone calls. I’m seeing a wave of medical friends and colleagues struggling with confidence and I do not know if it’s the age or career stage or just the nature of medicine.

A newly fellowed surgeon explained her drive and desire to operate on complex, technically difficult and physically challenging cases but an overwhelming sense of intimidation and low confidence was preventing this. Another similar-aged surgeon explained her main barrier to working private was the lack of available nearby “back up” from senior surgeons making her lack confidence in the event of complications. The same motif was echoed by a radiologist when I wondered why she was solely working public; because she was not yet confident in solo reporting and the clinical independence of private work.

While these reservations may suggest insight into safe boundaries of capability, being “in the deep end” may be an inevitability of senior medical practice and confidence is needed to face this.  

As GPs, we know autonomy and independence can be some of the most appealing aspects of general practice. However, it can also be very isolating and demands a lot of clinical competency and confidence.

In my after-hours clinics, I am usually the sole GP at the practice, with the support of a nurse and receptionist. I love the quietness of the waiting room and working consistently in this trusted very small team of three women. I also love the challenge of being the solo doctor, but it is very tough at times. In the years I’ve run the Sunday morning clinic, I’ve managed very unwell patients with sepsis, rapid AF, STEMIs, anaphylaxis, generalised tonic clonic seizures, massive gastro-intestinal bleeding, delivered a baby and more until we can get paramedic back-up, or the patient is stable.

Even outside of emergency situations, good general practice takes a lot of confidence. We work alongside other GPs, but every consultation is really only the doctor and the patient. The first presentation of whatever unknown illness, then subsequent history, examination, differential diagnosis, and management is entirely done on the fly, independently and confidently, within 10-15 minutes.

We do have the luxury of time and follow up, and can get specialist help in non-urgent situations, GP colleagues help between reviews, and ambulance crews can help urgently.

However, when I am the solo GP at 8.45pm on a Thursday and we have a persistently seizing child, it takes some mighty confidence to manage the situation until help comes. And I work in a metropolitan Melbourne practice 15 minutes away from a hospital; I am blown away by rural generalists and their unparalleled skill and confidence in solo practice.

Personally, I do generally feel confident and safe in my clinical skills and medical care. I get reassurance and reinforcement of this regularly through packed appointment books, patient feedback and safe outcomes.

That’s not to say I don’t have cycles of higher and lower confidence. If I miss a diagnosis or have a complication; confidence gets hit for a while. Perhaps during this period, I over-investigate and over-treat until the baseline confidence comes up again.

An old mentor drilled into me; if you haven’t had a complication, you haven’t done that procedure enough. I think of this daily, as I try to confidently manage uncertainty, undifferentiated illness, and an unending clinical scope of general practice, trying very hard to not have a complication but equally to be experienced and practiced enough to expect a complication at some point.

What surprises me is how many of us, as doctors, struggle with confidence more generally.

I do. I don’t know how to navigate the space between insecurity and humility, and confidence and arrogance. I deeply trust my “gut instinct” when it comes to clinical practice; it protects me time and time again, and it protects patients. “Systems 1” thinking is confident, brave, and consistently shown to save lives in healthcare, and the more I practice, the more concrete and accurate my systems 1 thinking seems to be.

But this confident gut instinct fails me regularly in all non-clinical and personal settings. I worry I am not competitive for academic endeavours for which my mentor firmly tells me I am extremely over-qualified. If I am asked to give an important talk, my instinct is to assume it’s because I “market well” as a young brown woman in a world of tokenistic diversity. I miss opportunities and big courageous decisions all the time because I second-guess my qualities or worth.

Furthermore, I am deeply shy and profoundly introverted, which people rarely believe because my innards don’t match my extremely confident appearing outwards. It is a continual deliberate and intentional effort to confidently present myself as a doctor, or speaker, or writer, or researcher and more. It is not my natural tendency. Networking is far, far outside my comfort zone. So, too, is calling specialists, or presenting my opinion at a committee meeting, or publishing very vulnerable writing.

I do these things because it is needed for my patients, it’s good for my personal growth, and it is my job to advocate for people who don’t have a voice as loud or wide-reaching as mine, even if I need to dig very deep into a well of confidence to do it.

Is it the same perfectionist tendencies that medicine feeds and grows into these wild beasts of insecurity?

We don’t get confidence training as doctors and being overconfident clinically can harm patients, hence there is understandable hesitancy from younger consultants to step into new levels of responsibility. Arrogance is also a very unpleasant and unattractive quality in a doctor, so good doctors will try to retain humility and caution. However, we operate in a system that fiercely stigmatises and punishes failure and vulnerability, so openness about insecurity or low confidence may be misinterpreted as clinical inexperience or lack of skill.

Consider as well that the mistakes we make are much costlier and harder to overcome than others, and despite acceptance that we are not defined by our job, and we are not only our job, medicine becomes a really massive part of our personality and identity. Therefore, our confidence in the “professional” version of ourselves will inevitably impact our confidence in our “personal”, and vice-versa.

There are definitely groups of doctors who need to be confident not arrogant. But equally there are doctors who need to be confident not insecure, second-guessing, and wracked with doubt, including, perhaps, me.

Whether it is imposter syndrome or personality or toxic medical cultures or fear of failure that drive these crises of confidence, the treatment is the same; constant reinforcement to ourselves that we are capable and worthy, and some mighty brave moments of confidence may bring unbelievable reward. And the unfortunate reality is that in medicine, we must be confident and capable and confident that we are capable because that is what our patients need.

The other unfortunate reality is that no amount of reassurance from others will help manage a confidence deficiency within ourselves, because confidence, like my Sunday morning list, is also a solo practice.

Dr Pallavi Prathivadi is a Melbourne GP and an adjunct senior lecturer at Monash University, with a PhD in safe opioid prescribing. She was a Fulbright Scholar at the Stanford University School of Medicine in 2020-2021 and the 2019 RACGP National Registrar of the Year.

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