Alika Lafontaine an Alberta-based anesthesiologist and the president-elect of the Canadian Medical Association for 2022-23.
When I was training as a doctor, I attended a lecture in which we discussed a cognitive bias called the Dunning-Kruger effect – that is, the overestimating of our inexperience to perform a procedure, or conversely, the underestimating of our deep experience to do so. Being realistic about how little or how much we know is foundational to good clinical practice. Without it, there are significant potential consequences.
Using the language of mountain peaks, slopes, plateaus and valleys, David Dunning and Justin Kruger found that limited experience can actually give rise to unearned confidence. While we climb this mountain of hubris to its peak, circumstances have not yet led to true catastrophe, and a series of overcome emergencies has led to the feeling that you have resilient karma or magic hands. This myopic belief ignores the reality that an inevitable epic failure is just around the corner. Success never lasts forever.
I’ve climbed this peak myself many times. As an anesthesiology resident still learning how to manage airways, there was a brief moment where I thought my skills could meet any clinical situation. I was wrong, and the fall was sharp and painful. A valley of despair followed my fall from that high peak. Leaning into the discomfort and openly acknowledging the truth of where I was at was the only way to start walking out of that low point.
This bias is on full display in Canada’s health systems. After months of the COVID-19 pandemic and three waves that seemed to have avoided the worst-case scenarios many projected, some provincial governments accelerated into life “post-COVID,” as if it was over. The appeal of being “open for summer” was just too compelling. Today, however, the heady optimism of weeks not long past is hard to find. In Alberta, we are losing our footing on that cliff’s edge in real-time; Premier Jason Kenney has finally declared a public health emergency amid surging COVID-19 case numbers and ICU admissions are at levels never before seen in Alberta’s history. In Saskatchewan, where conditions are similar, a mandatory mask order in indoor public spaces has been reinstated.
The past three waves had us walking to the very edge, but never falling into the darkness below. Serial avoidance of catastrophe led to an underappreciation of the danger we were in and an overestimation of our exceptionalism. The stark reality is that we are as exceptional as everyone else. COVID-19 does not change its virulence or transmissibility as it crosses provincial borders. There are reliable signs this pandemic has overrun, or will soon overrun, health systems. We need all hands on deck to acknowledge that the ship is sinking.
Climbing that mountain and walking off the precipice is not inevitable, however. We can still learn from our own past experiences, and we can learn from other people’s successes and mistakes. In Ontario, for instance, there has been decisive and judicious use of previously successful public health interventions like mandatory masks and social distancing, while encouragement to be vaccinated has given way to mandatory vaccination in key settings. Emerging tools like vaccine passports are stemming what would otherwise be health-system catastrophes elsewhere in the country.
Providers are no longer waiting to see where governments will lead us. Front-line health care workers are functioning as early warning systems, identifying places where health systems are under stress or crumbling. I have never seen this level of advocacy and honesty from my colleagues; it is clear that none of us want our health systems to fall into the darkness. The warnings have become a deafening hum that is unlikely to recede in the near term.
The Dunning-Kruger effect is natural and human. We all arrive at our own peaks, sometimes repeatedly. At this point in the pandemic, amid a fourth wave dismantling our health systems, I am hoping we can step back and re-evaluate before we fall off that cliff, because if we can’t figure this out, the societal consequences will reverberate for decades to come. The interventions that have worked in the past will likely still work today. Let’s quit thinking that things will just be different this time around. That kind of biased thinking got us to where we are now.
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