Climbing Mt. Stupid: Examining The Dunning–Kruger Effect In Lower Extremity Peripheral Nerve Surgery

The neurosensory experience of savoring the taste of the medianoche that I had just bitten into quickly was quickly interrupted when Chamberlain’s phone went off. Pausing my focused mastication, I looked up away from the Cuban delicacy there on my plate to glare at him for not only having his phone go off but for the audacity that he had in actually answering the damn thing.

After painfully listening to his half of the conversation with him mumbling on and on while failing miserably in eating his fried plantain, he said, “I’m sitting with him here right now. Do you want to talk with him?” 

My head swiveled back and forth, with near whiplash-type torque. It was a wonder I didn’t spew fragments of the Cuban sandwich all over the restaurant because of the centripetal force of my gestural denial. No, that was not enough. Chamberlain sometimes has the social IQ of a wildebeest in heat. Has the man no sense of dining fairness?

“No, no,” I whispered while still grappling with the medianoche. My capitulation was signaled by the precise and deliberate placement of my gustatory focus back down onto my plate. Wiping my hands off on the white napkin ultimately was the flag of my surrender.

“Hello,” I said while wondering who I was going to be chatting with and what we were going to be discussing. As the cellular transmission was somewhat garbled, all I heard was “this is Dr. Someone from Somewhere in Nebraska.” 

I couldn’t even get out a response before he continued the conversation. “Does this neuropathy surgery stuff for diabetics really work?” Again, before I could respond, he fired off a litany of questions and then told me about his experience from 10 to 15 years ago.  

“So, I tried a tarsal tunnel surgery on this patient way back then and it didn’t work out so well. Toes turned black and he ended up with an amputation about six months later on one side. But the guy passed away from a myocardial infarction before he could retain legal.” 

Now I am holding the phone away from me like there is going to be some kind of bad death vapor coming out of it at any second and motioning to Chamberlain that I was going to kill him for this. There is no way he could have really said that. Did I hear a “whew” from him after he told me about not being able to retain legal? Was this a spoof? It had to be. He was putting me on.

After about 10 minutes of a conversation of which I probably contributed less than 20 seconds of content, I learned the following. One, this surgeon had done one tarsal tunnel surgery before that fateful one (actually two as that was bilateral) and had read how to do it in a journal. Two, he did not assess vascularity as he had read somewhere that circulation improved after this type of decompression surgery. Three, the patient did not really have neurological evaluation to see if there were any signs of entrapment. Four, the surgeon performed the tarsal tunnel surgery bilaterally. Five, he used vigorous monopolar cautery for hemostatic management. Six, the surgeon meticulously closed the flexor retinaculum with a non-absorbable 3-0 suture. Seven, the patient was in bilateral casts for four weeks. 

When the caller finally paused, I asked him, “What is it that I can help you with?”  

“Well,” he said, “I’ve got another one scheduled tomorrow morning and I was hoping I could get some pearls from you. I don’t like those black toes, you know.” 

With what I just had learned, I had to ask one more question. “So how do you know Chamberlain?”

“Right, somewhat out of the blue me actually talking to you.” He went on to tell me that Chamberlain had used him as a case example of the Dunning–Kruger effect a few years back for one of his treatises and they had kept in touch. It turns out that he and Chamberlain were tight, well, at least in his mind.  

I gave the gentleman a couple of subtle and respectful hints that maybe this was a surgery that he should put off until further workup could happen or at least refer the patient to a surgeon who specializes in peripheral nerve surgery. He would have not have any of those suggestions. He was “trained and had the privileges.” After all, he wondered aloud, “How hard is it really to do a tarsal tunnel surgery?” He insisted this case was going to get done.

I parted with a few suggestions, wished him good luck and handed the now greasy phone back to my socially inept colleague. 

Exploring The Phenomenon Of ‘Meta-Ignorance’

By now, Chamberlain had finished his lunch. “Interesting chap, eh?” I couldn’t answer with a completely sweet Cuban bread-stuffed pie hole as I was back to getting that delicacy fully ingested. So much for instant gratification. After a few more bites of the now cold sandwich and a good slug of water, I washed down the last bite. “Please explain to me what in the hell is the ‘Dunning–Kruger effect,’ and more importantly, why, Chamberlain, would you subject me to that?”  

“First of all, if I had not put you on the line with him, you would never be able to fully appreciate what I see frequently in all professions and especially with peer reviewers. Secondly, you had to hear ‘that’ in order to believe me.” 

“Karaoke,” I added.   

“Precisely. The singer, who never took one voice lesson, who thinks he is only one step away from discovery and then certain fame is imminent. Yes, he is permanently ensconced at the summit of Mt. Stupid if you refer to the Dunning–Kruger curve. Complete delusion,” Chamberlain lectured.  

Taking out a new fresh napkin from the table dispenser, he drew a curve with an X and a Y axis. “So, here’s how it goes. Kruger and Dunning published a paper back in 1999, "Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments."¹ The authors showed that pretty much any field, domain or profession has this psychological effect where there is an ’ignorance of one’s ignorance.’ Experience and expertise comprise the X axis, and confidence is the Y axis. As you can see, there is a huge spike of confidence right at the beginning of the curve where experience or expertise is almost none, and confidence is nearly off the chart. Many in the field call this ‘Mt. Stupid.’ You could place most residents at the end of their residency here. Yes, they are neatly perched on the summit, totally ignorant of their ignorance. This is also referred to as ‘meta-ignorance.’” 

I had to interject. “Aren’t you being a little harsh, Chamberlain?”  

“No, quite the opposite. We all have been on the mountain and we all return to it periodically. It is human nature, nothing more than reflexively nodding at someone you do not know who nods to you while walking down the street,” he offered. 

Chamberlain continued, “There is one more thing I have to tell you about regarding this psychological human phenomenon and that is about ‘reach around learning.’” 

“Now you’re totally BS-ing me, Chamberlain.” 

“Oh no. Those folks up on the mountain will take something they recall from an unrelated domain that is general, manipulate it and then ‘apply’ it to claim knowledge, or superiority in something they have no real idea about. Often, they will cite research that does not even exist but they are so convinced they could pass a polygraph without hesitation.”

I have seen this effect in not only myself but in others for decades. This includes the field of lower extremity peripheral nerve surgery, which is really, really difficult once you have played in this arena for a while and realize there are just things you will never know, and that maybe you attain true wisdom when you know enough, namely that you know you don’t know a lot. 

“Meta-ignorance” is also hidden by domain-specific belief and the perfect example of this is in podiatric surgery with “Morton’s neuroma.” We all know it is not a neuroma, a true compressive neuropathy, but it has been called that for so long (coined by a dude named Sandel in 1958), that even though everyone knows or should know that decompression is really superior—and far less damaging than cutting out a normal, but entrapped nerve, and screwing up the patient for life—thousands, if not hundreds of thousands, of these little bad boys are resected every year by those residents of Mt. Stupid carrying on in their merry way with their own self-delusion and ignorance.^2,3

In summary, lower extremity peripheral nerve surgery is complex and is a specialty in and of itself. Just because you have done a “few” surgeries, have seen a “few” and/or have the privilege and licensure to do the procedure, that does not mean that you will achieve the ultimate outcome.

I had to ask Chamberlain what the guy’s name was and what city was he from?  

“His name is ‘All of Us” and he sadly resides in Mt. Stupid, a place where we all hang out occasionally.”

If you have any desire in wanting to know more about what went wrong with the tarsal tunnel surgery, you want to see my critique of the “Man on the Mountain,” go to: https://youtu.be/NhVJAtYRzTw.  

References

1.      Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999; 77(6):1121-1134.

2.      Munir U, Morgan S. Morton Neuroma. Available at https://www.ncbi.nlm.nih.gov/books/NBK470249/ .

3.      Larson EE, Barrett SL, Battiston B, Maloney CT., Jr., Dellon AL. Accurate nomenclature for forefoot nerve entrapment: a historical perspective. J Am Podiatr Med Assoc. 2005; 95(3):298-306.