By: Dorene F. Balmer PhD, May Shum MD, Dan Schumacher MD PhD
Terms like confidence and comfort are used often and interchangeably in clinical learning environments, though admittedly, the distinction between feeling confident and feeling comfortable as a medical trainee is fuzzy. For example, in a longitudinal qualitative study, one anesthesia resident said, “Compared to last year, I feel more confident in my abilities in the OR and with medicine in general.” A few minutes later, he went on to say, “If I never did OB cases then I just wouldn’t feel comfortable if one came up.” When asked specifically about the difference between confidence and comfort, this resident explained: “Confidence is what is on the outside and comfort is what is on the inside. If I feel comfortable, I feel confident too, but I express confidence. Whereas I don’t express comfort, I just feel it.”
Terms that are noticeably missing from the quotes above are competence and entrustment, the language of competence-based medical education. We as clinical educators traditionally favor terms that suggest external objectivity and relegate confidence and comfort to the realm of subjective reactions. But if we listened to trainees throughout their long arc of training, perhaps we would find value in their language.
Stories from six aspiring doctors, told over the course of twelve years—from month one of medical school all the way into clinical practice—are powerful teachers (The Long Arc of Training: Six Stories of Aspiring Doctors; published by University of Toronto Press in 2025). A surprising lesson was the nuanced and temporal pattern in how trainees talked about confidence and comfort, and what those terms differentially pointed to. When they were medical students, confidence and comfort were aspirations: “You train to be more comfortable with difficult conversations, and you train to make it second nature.” When they were residents, feeling confident was an internal marker of progress, a signal that they were moving toward being ready for practice, “I think that my training so far has helped me feel skilled and confident in ways that I need to be to be effective at my job.” But only when they were near the end of residency or in fellowship did they entertain feeling comfortable. “It’s like a falling away of anxiety, just kind of being grounded and comfortable in your practice, whatever comes at you.” Feeling confident was a critical foundation but it was not the end game. Feeling comfortable signaled, within themselves, that they were ready for practice.
If we as educators in clinical learning environments would listen to trainees for a long time, we would start to appreciate how feeling confident is different from feeling comfortable. Confidence grows from the slow and steady accumulation of knowledge and skills. It reflects a proactive stance. It surfaces when, at the end of their intern year, a surgical resident knows the right way to do a fairly complex procedure. But confidence is tricky because it is not only a feeling; it can be a performance. For example, another resident in the longitudinal study said, “I still have a lot to learn so I need to tone down the confidence.”
Feeling comfortable in practice is knowing what to do and how to react when things don’t go as planned. Feeling comfortable builds on a foundation of confidence. Comfort is on the inside; it is inhabited. It shows up in how a fellow pauses in the middle of an operation, not out of fear, but because they recognize that it’s time to rely on their experience and intuition, not on a textbook. And in contrast to feeling confident, comfort cannot be performed. It can only be felt.
Contrasting terms like confidence and comfort with competence and entrustment elucidates differences in how trainees and clinical educators qualify readiness for practice. Readiness for practice has become a prevalent focus in the era of competence-based medical education, which starts with the end in mind: what educational outcomes must trainees meet to be ready to provide the care that patients need without supervision? Competence-based medical education emphasizes the patient-focused side of being practice ready. This focus is rightly placed – patients need physicians who can provide quality care to them without supervision. However, competence-based medical education may have overlooked the trainee-focused side of being practice ready. For trainees, readiness is not competence; it’s not even confidence. Rather readiness is feeling comfortable in practice.
Perhaps, then, our task as clinical educators is not to expect trainees to only adopt our language and how we talk about readiness for practice, but to listen more carefully to theirs. If we attend closely to the terms that trainees use, we may find they are reminding us that readiness for practice is not simply an objective outcome on an entrustment scale. It is a long and toilsome journey towards feeling comfortable.coming clinicians who can think, decide, and act responsibly when it matters most.
About the Authors
Dorene F. Balmer, PhD, is Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, and Education Scientist at the MedEd Research Collaboratory at the Children’s Hospital of Philadelphia.
May Shum, MD, is a rising chief resident in Pediatrics at the Children’s Hospital of Philadelphia. Her career interests include Hospital Medicine and Clinical Informatics.
Dr. Schumacher, MD PhD, is a tenured Professor in the Division of Emergency Medicine at Cincinnati Children’s Hospital Medical Center (CCHMC). His research focuses on competency-based assessment, including milestones, entrustable professional activities, and resident-sensitive quality measures (RSQMs). He is passionate about assessment approaches that are patient-focused, such as EPAs and RSQMs. A recipient of national and international awards for his research, he has garnered nearly $6 million in medical education research funding and has conducted multiple national studies.
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