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January 2011 Clinical Laboratory News: The Competence-Confidence Conundrum

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The Competence-Confidence Conundrum 
A Look at Self-Assessment

By Michael Astion MD, PhD
Editor, Patient Safety Focus
Professor of Laboratory Medicine, University of Washington , Seattle

Most of us interpret a confident manner as evidence of competence, and a hesitant manner as evidence of lesser ability. But in an interview published in Patient Safety Focus (1) with David Davis, MD, senior director for continuing education and improvement for the Association of American Medical Colleges, and an author of an influential systematic review of physicians’ lack of accuracy in assessing their own competence (2), he described research suggesting that confidence and competence are inversely correlated. Referred to as the confidence-competence conundrum, the inability of human beings to recognize their own shortcomings has implications for patient safety and continuing education in the lab (3, 4).

How good is your self-assessment? The University of Washington Department of Laboratory Medicine, in collaboration with an educational software company, Medical Training Solutions, administers a 10-question patient safety competency assessment exam two times per year to subscribing laboratories. Presented here are two questions taken from the second exam in 2010 in which more than 6,100 clinical lab workers from some 600 clinical labs in the U.S. and Canada participated. Here’s an opportunity to compare your answers with those from this sample of laboratory personnel. The correct answers, the overall score on the questions, and an analysis are presented to reinforce the concepts of the competence-confidence conundrum.

Question 1. True or False: Most incompetent workers tend to over-rate their ability.

Correct Answer: True

Explanation: The score on this question was 94% correct, reflecting an excellent understanding of the competence-confidence conundrum. To understand why true is the correct answer to this question, it is helpful to review Figure 1, which illustrates the competence-confidence conundrum. The graph shows the usual relationship between self-assessment on a task and the actual, objective assessment of that task.

The confidence-competence conundrum is a basic human characteristic that has been confirmed in more than 30 studies across many medical domains including surgery, nursing, and the clinical lab. It holds true for the majority of people, although there are individuals who are exceptions to the rule, for example, the incompetent person who is not confident in his or her ability. Simply stated, the competence-confidence conundrum refers to the two-fold burden that afflicts most incompetent workers. First, they are incompetent, and second they are unaware of it.
The American television hit, American Idol, offers great examples of the competence-confidence conundrum. Contestants who are eliminated early in the competition are awful singers by nearly any measure, but a majority of these cast-offs insist that they sing well.

Figure 1
Illustration of the Competence-Confidence Conundrum

Davis figure

For incompetent workers (bottom quartile), there is a gap between actual performance (blue rectangles) and self-assessment of performance (red rectangle, directly above blue). In contrast, for highly competent workers (top quartile), actual performance on a task tends to be slightly higher than self-assessment of performance.

Question 2. True or False: Supervisors should rely more on objective competency assessment and less on self-assessment for determining who can perform tasks that could affect patient safety.

Correct Answer: True

Explanation: The score on this question was 80% correct, lower than the correct score for Question 1. The question actually states what should be an obvious conclusion based on the recognition that incompetent workers generally over-express confidence. Because incompetent workers tend to overrate their ability, lab supervisors should not rely on self-assessments to determine which workers should perform tasks that are essential to patient safety. Rather, supervisors should use objective competency assessments.

The lower score on Question 2 compared to Question 1 shows that lab workers are clearly aware of the competence-confidence conundrum, but less knowledgeable about policies that can minimize its effect.


  1. The inability of people to recognize their own incompetence: an interview with David Davis, MD. Clinical Laboratory News 34 (10): 20–21. Freely available at:
  2. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, et al. Accuracy of physician self-assessment compared with observed measures of competence. JAMA 2006;296:1094–1102.
  3. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence leads to inflated self assessments. J Personality and Social Psychology 1999; 77:1121−1134.
  4. Haun DE, Zeringue A, Leach A, Foley A. Assessing the competency of specimen processing personnel. Laboratory Medicine 2000; 31:633–637.


Patient Safety Focus Editorial Board

Michael Astion, MD, PhD
Department of Laboratory Medicine 
University of Washington, Seattle

Peggy A. Ahlin, BS, MT(ASCP) 
Salt Lake City, Utah 

Corinne Fantz, PhD
Emory University
Atlanta, Georgia

James S. Hernandez, MD, MS
  Mayo Clinic Arizona 
Scottsdale and Phoenix

Brian R. Jackson
ARUP Laboratories
Salt Lake City, Utah

Sponsored by ARUP Laboratories, Inc.