Sarah, a new attending, has been asked to work with June, a PGY-1 resident who has struggled with new admissions.
On rounds, June recommends a urinalysis for a patient with advanced dementia and new agitation.
“Why a UA?” Sarah asks.
“Behavior changes can indicate a urinary tract infection in older adults,” June replies, confident and fluent.
Inside, Sarah splits. She wants to teach, to pause, invite uncertainty, and help June reason through delirium and the evidence behind testing. But she has also been asked to assess, to determine whether June is meeting expectations and to provide a description of where June follows on a Likert scale describing her performance.
She chooses assessment.
Sarah asks lots of follow-up questions: What symptoms exactly, labs, what is asymptomatic bacteriuria, what are the appropriate next steps? June’s answers get shorter.
That evening, June memorizes the answers Sarah seemed to want. Next time, she will perform better.
In trying to teach while assessing, Sarah taught performance, not reasoning.
The performance trap
When assessment dominates, learners adapt. They stop revealing uncertainty, cling to rules instead of understanding, and trade curiosity for self-protection. Over time, this shapes not just how they learn, but how they experience medicine. Educational psychologist Carol Dweck, in her book Mindset, describes how learning goals foster curiosity and engagement, while performance goals emphasize appearing competent.
When assessment is prioritized, it effectively frames learning as a performance goal. In June’s case, having a performance goal makes her more likely to learn the behaviors to signal competence to Sarah instead of trying to understand. Moreover, learners with learning goals are more likely to seek challenges and persist in the face of difficulty. In contrast, those pursuing performance goals tend to avoid risk and disengage when challenged. Within this context, June may begin to avoid cases that would expose gaps in her knowledge.
The relational cost
Beyond June’s perspective, Sarah, the attending physician, also experiences moral distress arising from the tension between her desire to build a supportive, growth-oriented relationship and her obligation to formally evaluate June’s performance. Psychologist Carl Rogers identifies core relational elements that foster growth and emphasizes the educator’s responsibility to “free the learner from the threat of external evaluation” to promote curiosity and the development of a “self-responsible person.”
Sarah understands, at a fundamental level, that for June to grow and seek knowledge independently, she must empower June to take ownership of her education and be freed from the constant threat of assessment.
Cognitive rigidity and competition
As June progresses through her training, she will encounter countless patients with delirium and review many urine cultures, yet each case will carry its own nuances. She will also work with many attending physicians beyond Sarah, each bringing different expectations for trainees. In response, June will become distressed with the diversity and long for clear rules. She may become cognitively rigid in her approach to cases, seeking certainty as a form of protection. In doing so, she will be less likely to reflect on the underlying “whys,” relying instead on memorized “whats.”
The assessment culture not only undermines relationships both with attendings and residents but also between residents themselves. Educational research suggests that the act of grading itself can promote unhealthy peer relationships, where students view each other as rivals rather than collaborators. This can lead to social isolation, decreased empathy, and an overall decline in the quality of peer interactions.
Reimagining the dynamic
Think again about how the environment could be different. Sarah was not asked to identify where June falls on a Likert scale but was asked to understand June’s perspective and collaborate on learning goals. June would ask Sarah for the aspects of her medical care that she wants feedback on. June and Sarah would both commit to the topics they would like to learn more about together. Instead of assessment, they had decided that learning and inquiry would be their objectives.
Letting go of metrics and constant assessment can be deeply unsettling for medical educators, in part because it feels like relinquishing control over a costly and high-stakes training process. There is undeniably a role for assessment in ensuring public safety. However, care must be taken to ensure that it does not harm the learning environment. Assessment’s role in medical education is to establish a floor, not to reduce trainees to a label or a number on a scale. It is ill-suited to cultivating excellence because it impedes growth, inquiry, intrinsic motivation, and adaptive thinking.
As assessment becomes increasingly prioritized in medical education, physicians are incentivized to become increasingly rigid in the care they provide. They will be more likely to become distressed with uncertainty and find less joy in their careers. It is essential that medical educators move from prioritizing assessment to promoting growth, autonomy, curiosity, and psychological safety. Only in this setting can physicians and patients truly thrive, and the public can get the care they need. Once assessment becomes the floor and growth becomes a priority, there is no limit to what medical education can achieve.
Mythili Ransdell is an internal medicine-pediatric physician.
