I’m often struck by how frequently residents say, “I want to be more confident.”
As educators, we often assume that means they need more skills, more knowledge, or more experience. We tend to treat "lack of confidence" as a "lack of competence."
Recently, I was reminded that this assumption is often wrong.
The Competence-Confidence Gap
In a coaching conversation with a resident who was clearly clinically capable, I asked what sat underneath her desire to be “more confident.”
What emerged wasn’t incompetence—it was fear and self-doubt.
It was a fear shaped by earlier training experiences where expectations were unclear, harsh feedback arrived late, and mistakes felt costly.
These experiences, often driven by the behaviors of teaching attendings, had quietly eroded her confidence.
By the time she became a senior resident, her competence had grown. From my perspective, her clinical reasoning was sharp and her management plans were solid. Yet, her confidence lagged behind.
The old internal questions lingered: “Am I doing the right thing?” “I should just do what my attending suggests—they have more experience, so they must be right.”
In her case, “I want to be more confident” was actually a plea for protection (and freedom) from self-doubt. It was then that the distinction became clear to me: Confidence is not the same as competence.
Competence grows through training and experiential learning.
Confidence grows through how we make meaning of those experiences and how we define our “being” as a physician.
The Origin of Fear-Based Values
Clinical training is full of judgment. It can feel insulting, even scary, to receive harsh evaluations. Because "good" evaluations are often the primary metric of success, most physicians spend their careers trying to avoid the "bad" ones. We are conditioned to avoid criticism at all costs—even as attendings—because of how much it hurts our professional standing and our psyche.
From a psychometric perspective, rater-mediated assessment in a clinical environment is heavily rater-dependent. Because the context changes every day, these assessments are inherently biased and "judgy." Even a single harsh comment can diminish a learner's self-efficacy.
An example from my own life:
I often catch myself thinking: “I need to find and create more teaching moments.”
While that sounds noble, the underlying driver is fear-based: “If I don’t, my learners won’t get the best experience, and I won’t get the teaching evaluation scores I want.”
Shifting Toward Conscious-Based Values
Through coaching, I’ve learned that true confidence starts with "being." When a learner identifies who they want to be and what matters to them, they find the insight needed to navigate patient care.
If ensuring a patient feels heard is your core value, you will intentionally listen without judgment.
If building trust is what matters, you will naturally follow through and communicate with consistency and reliability.
If "doing the right thing" is the goal, you will take the necessary time to exhaust every option.
I once heard a medical student say: “I may not receive gratitude from every patient, but it is important for me to know I have done everything I could.”
In inpatient medicine, we have limited control over outcomes. But we have total control over who we choose to be when we walk into a room. When we shift our focus to fulfilling these conscious values, we reframe the meaning of our work.
Case Continued: From Deference to Dialogue
When I asked this resident what thought might serve her better as a capable PGY-2, she struggled to find an alternative to self-doubt (that is understandable).
I shared what helps me in those moments: I don’t try to eliminate the fear. I anchor to curiosity instead. If I am curious, I stay open. If I am open, every experience—even the uncomfortable ones—becomes an opportunity to learn. From that place, confidence doesn't depend on being "right." It comes from knowing I can adapt.
This reframing opened a door for her. She realized her greatest strength was as a connector. Patients felt heard by her; colleagues enjoyed engaging with her. She realized she could leverage that strength when facing a difficult management plan.
Instead of silently defaulting to the attending's plan, she decided to communicate her reasoning transparently:
“If I explain how I’m prioritizing options and why I’m choosing this approach, I can try my own way without it feeling confrontational.”
Her confidence didn't come from being certain or right. It came from an awareness of her "being" and the ability to leverage her strengths to engage in open dialogue.
Coaching Takeaways You Can Try
If you are working with a learner (or yourself) who is struggling with confidence, try these shifts:
Ask Clarifying Questions:
"What does 'being confident' look like to you in this specific situation?"
"What makes committing to your own plan feel important right now?"
"What is the specific thought that comes up when you feel you don’t commit to a plan?"
Normalize Uncertainty:
When sharing your own approach, ask: "How are you prioritizing these options?"
Micro-feedforward: Create safety by clarifying expectations and giving real-time "feedforward" during the task, rather than a post-mortem evaluation at the end. Prevent your learner from going back to their old pattern.
The Bottom Line:
Confidence isn't about the accuracy of the plan. It’s about understanding your "being," acknowledging your fear, and trusting that you can learn and grow—even when things don’t go perfectly.
“When you say you want to be more confident, what’s the thought underneath that?”
Hirotaka Kato, MD, MEd
Clinician-Educator, Physician Peer Coach, Hospitalist
LinkedIn: www.linkedin.com/in/hkato01
