Issue: 2018 > March > editorial

Distrusting confidence

Y.M. Smulders
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I remember my first out-of-hours service vividly. The fear and agony were immense. I had been a resident for just a few weeks and there I was, alone, responsible for over 60 beds and a crowded downtown Amsterdam Emergency Room. I was convinced that the first person needing resuscitation was gonna be me. But no one died. The ER personnel, particularly some of the older nurses, knew exactly who they were dealing with, offered guidance and support, and pretty much pulled me and my patients through the night. 
Needless to say I didn’t feel ready for doing shifts at the time, but nor did I for several years afterwards. And believe it or not, I still sometimes feel not-ready for doing what I am supposed to do, and what others might think I am well-qualified for. My latest weekend supervision, for example, I started feeling insecure and tense. No one noticed, I guess, and once I was doing rounds on the ER and wards, the feeling gradually subsided.

Elsewhere in this issue, Baten et al. report that many residents feel insufficiently prepared for their first out-of-hours service.1 Among other factors, having at least a few months of experience and some form of targeted training and assessment offered some protection against ‘feeling unready’. The authors find this disconcerting, and argue that the results actually reflect insufficient preparation of residents starting out-of-hours service.
However much I sympathise with junior residents starting out-of-hours service, I think feeling ready is a very poor substitute for being ready. Having said that, I unreservedly acknowledge that, particularly in the old days, many residents start(ed) doing shifts almost totally unprepared, harming themselves and patients alike. Has that caused casualties? Certainly so. Residents entering shifts which include responsibility for critically ill patients should have at least several months of clinical experience. Targeted training is mandatory in most hospitals and specialties and apparently boosts self-confidence, although I am uncertain if it really improves care and patient safety. Before a resident starts doing shifts, the supervisors should explicitly agree that the necessary medical and communicative skills are up to standards.

If all the above conditions have been met, residents will start their first shift sufficiently prepared, but feeling either very secure, completely insecure or, most often, somewhere in between. ‘Who would I like to look after my sick family’, is a question that reportedly correlates well with residents’ quality of care. For me, the answer is easy: get me an insecure one. I just don’t trust self-confidence.
We should make sure that residents starting out-of-hours service are adequately prepared. If they feel unprepared nonetheless, we need to address that, but the message must be that it is okay to feel insecure, that we trust and support them, and that help is never far away. Along the way of medical training and professional careers, we must remember that feeling insecure is a virtue, protecting us from over-confidence and cutting corners.


  1. Baten A, Bleeker-Rovers CP, van den Heijkant F, de Graaf J, Fluit CRMG. Residents’ readiness for out-of-hours service: a Dutch national survey. Neth J Med. 2018;76:78-83.