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Addressing the Confidence Gap in Audiology

Rudden, D'Anne, AuD

doi: 10.1097/01.HJ.0000544482.57644.f4
Special Section: Promoting Confidence in Audiology

Dr. Rudden is the owner of Longmont Hearing and Tinnitus Center in Longmont, CO, and an adjunct professor at the University of Colorado.

My battle with self-confidence began on my first day of school. I was so excited to ride the big yellow school bus and sit at my very own desk. I was vibrating with excitement when that day finally came. The teacher began to take roll call, and about halfway through her list, there was a pause. A long pause. The teacher attempted what would become a life-long struggle of having to explain how to pronounce my name. “Dane?… Danny?” she said as giggles erupted across the classroom. I slowly raised my hand to correct her. “It's Dee-Anne,” I said with a touch of whispered defeat. “There's an apostrophe in between the D and the A.” More giggles. The teacher tried to cover it with a look of self-effacing guilt, but the damage was done.

Figure 2.

Figure 2.

Table 1

Table 1

This story played out each year on the first day of school and, in fact, became a running joke among my classmates. On the outside, I learned to put on the armor of “whatever.” On the inside, I wanted to crawl under my desk. Today, over 40 years later, I still get what my mother refers to as “the-night-before-the-first-day-of-school blues” the night before I start anything new.

My first day of school initiated a gap between who I am and who I could be. I used to believe that confidence was just something one comes with; you either have it, or you don't. But in reality, there are confidence gaps between who we are, how we are seen, and what we could be.

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SCIENCE OF CONFIDENCE

Over a century ago, William James said that most people live in a restricted circle of potential. The reason so many people never fulfill their potential is not a lack of intelligence, opportunity, or resources; it is often a lack of belief in themselves or too little self-confidence.

On the flip side, some people have an inflated view of what they care capable of accomplishing. This overconfidence is thought to be the result of a miscalibration of the brain chemistry and function. It often plays out in a systematic overestimation of an individual's ability to predict their own success, typically not in a single situation but most likely on a massive scale (Kay & Shipman, 2014). Researchers go even further to say that experts in any field of study suffer more from overconfidence than laypeople do, and that overconfidence is more pronounced in men while women tend to underestimate themselves and their abilities (Alpert & Raiffa. In, Kahneman, et al. (eds), 1982; Kay & Shipman, 2014).

So, if confidence—over-confidence or a lack thereof—is not a fixed attribute, what exactly is it?

Confidence comes from a complex neurophysiological response in your brain originating from the amygdala, hippocampus, and prefrontal cortex:

  • The amygdala is responsible for the fight-or-flight response.
  • The hippocampus is responsible for long-term memory.
  • The prefrontal cortex is responsible for executive function.

When the amygdala activates, the fight, flight, or freeze response hijacks your brain. In any of these three states, most of your physical and mental resources are reallocated to ensure you survive. Survival in modern times generally equates to situations of high stress–when you cross paths with an angry partner, an unhappy boss, a rude driver, or even challenging patients.

Further studies reveal that emotional arousal during an event influences the strength of the memory for that event. The greater the level of emotional meaning you assign to an event, the better your retention is of that event. Unfortunately, we usually have the greatest emotional responses to negative or fearful happenings (Behav Neurosci. 1992 Apr;106(2):274).

The hippocampus, also a part of the limbic system, then transfers the experience into long-term memory, which affects a person's confidence, especially if the event was logged as negative (Behav Neurosci. 1992).

Confidence finally emerges after events are processed in the prefrontal cortex. The basic activities performed by the prefrontal cortex impact our ability to:

  • differentiate among conflicting thoughts,
  • determine differences among pairs such as good/bad, better/best, same/different,
  • understand future consequences of current activities,
  • work toward a defined goal,
  • predict outcomes, and
  • have expectations based on actions (ScienceDaily. Feb, 2006).
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PSYCHOLOGY OF CONFIDENCE

So where does that leave us? Are we truly born with confidence or not?

Studies from social psychologist Richard Petty, MD, and his team demonstrated that self-esteem is how you perceive yourself, while confidence is how sure you are that your self-perception is true. Some studies found that confidence is a magnifier of our thoughts and feelings, but these results can be manipulated (Kay & Shipman, 2014). But beyond having thoughts and experiences, how we feel about our thoughts and actions and how confident we are about those feelings are critical. Basically, confidence is more than biology. Biology is not destiny, but understanding the science behind confidence can be a powerful tool to drive positive changes.

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CONFIDENCE IN AUDIOLOGY

When I started my research on the impact of confidence on audiology, I found many anecdotal stories but a dearth of scientific research on audiology or other similar professions. Notably, I found a clinical questionnaire called the Evidence-based Practice Confidence Scale (EPIC), developed by Salbach and Jaglal in 2011 (J Eval Clin Pract. 2011 Aug;17(4):794). The EPIC scale measures confidence of health care professionals in their ability to perform specific steps in evidence-based practice. Previous studies have found significant evidence on the ability of self-efficacy to predict a professional's successful outcome (Am J Occup Ther. 2016;70(2):7002280010p1). In a 2012 Australian study, audiologists were included in the data but were not separated from other allied health professionals (J Allied Health. 2012 Winter;41(4):177).

With the movement of audiology toward an evidence-based model, I conducted a non-scientific study to see if my suspicions about the impact of confidence on audiology could be quantified. A total of 120 responses were received between May 16-20, 2018, using a Qualtrics online version of the EPIC survey (see Appendix A). Additional responses were recorded but not included in the data calculations due to time constraints.

Most respondents were female (85.6%), which is consistent with the 2016 diversity data for audiology that reported an overall ratio of 88.9 percent female to 11.1 percent male (Data USA, 2016). About 52 percent of the respondents had Zero to 10 years in the profession, and 48 percent have been in the practice for 11 to over 30 years. This is the breakdown of the 120 respondents by work setting: hospital - 16; ENT/physician practice - 15; private practice - 62; school/university - 25; manufacturer - 2.

Key findings showed 92.1 percent mean confidence average (MCA) with a standard deviation (SD) of 11.68 in the respondents’ overall confidence in their ability to ask patients about their needs, values, and treatment preferences. Over 85 percent MCA (13.3 SD) of audiologists surveyed reported having confidence in their ability to decide on an appropriate course of action based on integrating research evidence, clinical judgment, and patient preference. Is this a testimony to overconfidence in their clinical skills?

The audiologists surveyed showed a distinct lack of confidence in their ability to interpret and use research data, including those gathered using various statistical procedures. (51.3% MCA; 29.5 SD). The collective confidence to critically appraise the strengths and weaknesses of study methods (such as appropriateness of study design, recruitment, data collection, and analysis) and measurement properties used (e.g., reliability and validity, sensitivity and specificity) was only slightly better (69.3% MCA; 22.5 SD). Do these results show a lack of confidence as we seek to become an evidence-based profession?

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THE ALCHEMY OF CONFIDENCE

One way to think of confidence is that it is part of our natural state, but circumstance and story affect the lens through which we see who we think we are. It is our inner work to change these perceptions. Table 1 is a brief version of my four-step confidence practice based on the principles of alchemical transformation that you can integrate into your daily life.

Each of us must practice confidence individually, but it's also vital to address the larger question: How can audiology become more cohesively confident? It's going to take an alchemical shift in how we treat the importance of confidence in recruiting and training young professionals, as well as a shift in the content of professional development courses offered to seasoned colleagues.

We can all improve our skills in areas of deficit, but do we have the confidence to admit that we need more?

Evidence shows that confidence correlates higher with success than competence (Kay & Shipman, 2014). If this is so, then we must make the practice of confidence an integral part of moving the audiology profession forward.

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