**Sarah, a New Attending, and the Difficulties of Balancing Evaluation and Educational Objectives**
Sarah, a new attending doctor, encounters a significant challenge in her teaching responsibility while collaborating with June, a PGY-1 resident. June has struggled with new patient admissions, a situation that requires careful oversight and support from Sarah. During rounds, June proposes conducting a urinalysis for a patient with advanced dementia who is showing new signs of agitation. Her justification is that behavioral changes could indicate a urinary tract infection in elderly patients, illustrating her expanding knowledge.
Yet, Sarah feels conflicted. She aims to cultivate a learning atmosphere and motivate June to accept uncertainty and enhance her reasoning regarding delirium. Additionally, she considers the evidence supporting specific medical tests. Nevertheless, Sarah is also responsible for evaluating June to assess her performance levels, prompting her to provide an appraisal based on a Likert scale detailing June’s performance.
Sarah opts to emphasize the assessment component, engaging June with various follow-up inquiries regarding symptoms, required labs, asymptomatic bacteriuria, and suitable subsequent actions. June’s initial confidence diminishes as her answers become shorter and less certain.
That evening, June contemplates the incident and resolves to memorize the responses that Sarah seemed to expect. Her goal is to showcase improved performance during their next interaction. In this situation, despite Sarah’s intention to instruct, her dual role led to imparting knowledge centered on performance instead of nurturing deeper reasoning abilities.
**The Performance Trap**
When evaluation dominates learning, students frequently adapt by concealing their uncertainties. They lean on strict rules rather than authentic comprehension, compromising curiosity in favor of self-preservation. This environment may alter their approach to medicine, as noted by educational psychologist Carol Dweck in her book “Mindset,” which differentiates between learning objectives that foster engagement and curiosity and performance objectives aimed merely at demonstrating competence.
For June, concentrating on performance objectives might result in her mimicking behaviors that convey competence to Sarah instead of genuinely grasping the material. Learners inclined towards learning objectives are more likely to embrace challenges, while those fixated on performance may evade risks and detach when faced with difficulties. This could lead June to overlook cases that expose gaps in her understanding.
**The Relational Cost**
Sarah faces her own set of challenges. She feels moral distress from balancing the necessity of fostering a supportive educational relationship with June while satisfying her duty to conduct a formal evaluation. Psychologist Carl Rogers highlights the significance of promoting growth by liberating learners from the threat of external assessments, thereby encouraging self-reliance and curiosity.
Sarah understands that to enable June to independently seek knowledge, she must reduce the constant presence of judgment and empower June to take control of her education.
**Cognitive Rigidity and Competition**
As June progresses in her training, she will encounter various cases of delirium, each distinct, and will collaborate with several attending physicians, each with unique expectations. This variety may create distress, fostering a longing for clear, established rules. Consequently, June could become cognitively inflexible, focusing on memorizing responses instead of comprehending foundational principles.
A culture that prioritizes evaluation can also strain relationships among residents, as indicated by educational research suggesting that grading may encourage unhealthy peer rivalry instead of teamwork. This dynamic can lead to social isolation, reduced empathy, and diminished quality in peer interactions.
**Reimagining the Dynamic**
Consider an alternative approach: instead of defining June’s role through evaluation, prioritize understanding her perspective and collaborating on shared educational objectives. June could seek specific feedback from Sarah regarding areas of interest. They could mutually commit to exploring topics of common interest, focusing on inquiry and comprehension rather than assessment.
Although relinquishing constant evaluation may be challenging for medical educators due to its perceived authority over medical training, it is essential to ensure that assessment does not undermine the learning setting. Evaluation should create a baseline for competency without reducing trainees to mere labels or scores.
When medical education emphasizes growth, curiosity, autonomy, and psychological safety over rigid evaluation, both physicians and patients benefit, and the public receives the care it rightfully deserves. Prioritizing growth over simple performance can unlock the true potential of medical education.