Downloaded from http://journals.lww.com/anesthesia-analgesia by BhDMf5ePHKbH4TTImqenVLR44w6OFdZPF5noL6085/QnsCrwmzhyYWPdlGD572Q5 on 03/01/2020 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. e172 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA E LETTERS TO THE EDITOR Heuristics, Overconfidence, and Experience With Management of Neuromuscular Block: Self-Correction Is Unlikely To the Editor T he central thesis of our article 1 was that overconfdence in the accuracy of one’s own intuition was a possible reason for many anesthesiologists’ unwillingness to use quantitative neuromuscular monitors. Failure to moni- tor antedates the availability of quantitative monitors; it was equally true 30 years ago, when inexpensive peripheral nerve stimulators were ubiquitous. Harman et al 2 comment that “… a causal link between overconfdence and neuromuscular blockade monitoring remains unproven.” If it were possible to randomly assign anesthesiologists to varying levels of confdence in their own intuition and assess each anesthesiologist’s use of monitoring, then a causal link could be proven. Obviously, that experiment is impossible. But overconfdence is the most likely explanation. It would have been extremely help- ful had Harman et al 2 provided an alternative explanation. Many publications are highly suggestive (and there- fore are supportive) of this thesis in different professional domains. 1 Arkes et al 3 found that in a baseball judgment task, experts used a helpful decision rule less frequently, but performed worse than those with moderate baseball knowl- edge. Meyer 4 found that in choosing a diagnosis, physicians with higher confdence in their diagnostic performance Karsten Bartels, MD, PhD Department of Anesthesiology University of Colorado Anschutz Medical Campus Aurora, Colorado karsten.bartels@ucdenver.edu Paul S. Pagel, MD, PhD Clement J. Zablocki Veterans Affairs Medical Center Milwaukee, Wisconsin REFERENCES 1. Benumof JL, Manecke GR. Scholarly activity of anesthesiology residents. Anesth Analg. 2019;129:e171. 2. Ford DK, Richman A, Mayes LM, Pagel PS, Bartels K. Progressive increase in scholarly productivity of new American Board of Anesthesiology diplomates from 2006 to 2016: a biblio- metric analysis. Anesth Analg. 2019;128:796–801. 3. Manca A, Cugusi L, Dvir Z, Deriu F. PubMed should raise the bar for journal inclusion. Lancet. 2017;390:734–735. 4. Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Anesthesiology. Available at: https://www.acgme.org/por- tals/0/pfassets/programrequirements/040anesthesiology2018. pdf. Accessed June 26, 2019. DOI: 10.1213/ANE.0000000000004369 were less likely to request additional tests. In each of these examples, overconfdence led to less or no use of cognitive aids or tools that would improve outcomes. We stated that “… the survey results may not be an accurate representation of practicing anesthesiologists worldwide. 1 ” We disagree that “without descriptive infor- mation on respondents and their clinical practice patterns, describing the response population as overconfdent ver- sus more experienced … is diffcult. 2 ” That 92% of the anesthesiologists were overconfdent indicates that dif- ferences in clinical practice and other factors could not have played a signifcant role in qualifying our results. 1 Furthermore, we noted that experience played no role in any dependent variable. Harman et al 2 wrote, “Statistically, an individual who knows nothing about the topic might correctly guess the answers to 50% of true/false questions ...” In their example, 2 they use 2 scales that are bounded differently. Someone who knows nothing about a topic will correctly answer about 50% of the questions. Therefore, the accu- racy scale is bounded at the top by 100% accuracy and at the bottom by slightly <50% accuracy. The confdence scale suggested by Harman et al 2 has boundaries of 0% (“zero understanding”) and 100% (“total understanding”). Because calibration is assessed by comparing accuracy and confdence, there are major issues with comparing variables on different scales. The advantage of our use of 2-option, true/false questions and then placing the conf- dence rating on a 50%–100% scale 1 is that the 2 variables can be compared directly on isomorphic scales to assess calibration. We believe that merely acquiring a quantitative monitor will not solve postoperative residual neuromuscular block, and we maintain that strong educational efforts are needed. We also might take comfort in the fact that a majority of the general population are overconfdent, too. Mohamed Naguib, MD, MSc, FCARCSI Department of General Anesthesia Cleveland Clinic and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland, Ohio naguibm@ccf.org Sorin J. Brull, MD, FCARCSI (Hon) Department of Anesthesiology and Perioperative Medicine Mayo Clinic College of Medicine and Science Jacksonville, Florida Jennifer M. Hunter, MBE, MBChB, PhD, FRCA, FCARCSI (Hon) Department of Musculoskeletal Biology University of Liverpool Liverpool, United Kingdom Aaron F. Kopman, MD Retired New York City, New York Béla Fülesdi, MD, PhD, DSci Department of Anesthesiology and Intensive Care University of Debrecen Faculty of Medicine Debrecen, Hungary Ken B. Johnson, MD Department of Anesthesiology Conficts of Interest: M. Naguib served as a consultant for GE Healthcare in 2018. S. J. Brull has intellectual property assigned to Mayo Clinic (Rochester, MN); has received research funding from Merck & Co, Inc (funds to Mayo Clinic) and is a consultant for Merck & Co, Inc (Kenilworth, NJ); is a principal and shareholder in Senzime AB (publ) (Uppsala, Sweden); and is a mem- ber of the scientifc advisory boards for ClearLine MD (Woburn, MA), The Doctors Company (Napa, CA), and NMD Pharma (Aarhus, Denmark).