The life of a physician is rife with standardized testing. As I approach the end of residency and prepare for my written boards, I reflect back on the alphabet soup of exams I have taken to get to this stage — ACT; SAT; Step 1, 2, 3; ITE. Though I may grumble at all the work, it’s clear that standardized testing has a purpose: Each test ensures that I have obtained the requisite knowledge to advance onward; each test is a means of realizing some degree of quality control within our profession. And yet, our tests are not morally neutral; whether intentional or not, they can perpetuate the dogmas of the past, codifying various disproved or harmful concepts and notions.
I have noticed these dogmas several times while doing my exam prep work. For instance, my exams in medical school used to say that the Glomerular Filtration Rate was affected by race, with a racial modifier utilized to calculate kidney health between Black and non-Black patients. The modifier led to artificially increased estimates of kidney function, which led to delays in receiving renal care. It was not until the past several years that many institutions began to reassess the studies advocating for separate GFR calculations, and this reappraisal has led to many hospitals moving away from equations that utilize these racial modifiers.
More recently, I have noticed that my board exams are still making reference to the “ideal nose.” The laundry list of factors that make up this nose includes exact measurements and specifications, as if we are preparing to build a cabinet or cook a dish. A 30 to 40 degree nasofacial angle, 120-132 degree nasomental angle, a perfect 3/4/5 triangle. As I study the diagrams in preparation for the exam, I glance at a family photo hanging on the wall, noting the stark discrepancy between our noses and my textbooks. I certainly was never under the illusion that I have a perfect nose, though these values offered a quick reminder of all of the ways that I felt othered growing up.
This recent experience led me to drill down into where the numbers for “ideal noses” come from. Searching through the annals of medical history, I was surprised to learn that they aren’t necessarily derived from research on normative nasal values, but rather borrowed from art. Though allegedly based on firm science, our conception of what makes a face appealing is actually indebted to ancient Greek artists and mathematicians. The 5th century Greek sculptor Polykleitos was one of the early proponents of mathematical ratios being key to beauty. In his “Kanon,” he lays out the notion that proportionality is the core tenet in beauty. The relationship of varying body parts to one another could be represented mathematically, and adherence to these ratios led to beauty. In the Renaissance, artists continued to apply this notion of set bodily ratios to the face, creating what would become known as the neoclassical canons of facial proportions. What started as artistic standards eventually found their way into the medical field, influencing anatomists. Ernst Brucke, a physician and professor of Sigmund Freud’s, felt that this aesthetic sensibility was essential when learning anatomy, claiming, “It is certain that anatomy, unless studied from the aesthetic aspect, is of little use.” The marriage of artistic principles with medicine continued into the 19th century, with these neoclassical canons forming the basis of facial reconstruction and aesthetic analysis.
And yet, although the neoclassical canon represents an idealized version of what the human body should look like, these standards are not as universal as we once thought. Numerous studies have found that, unsurprisingly, culture and country of origin play a strong factor in determining what a “normal” or appealing nose looks like. Though certain principles may hold across cultures, the notion that there are set numerical values that can universally predict what a face should look like is outdated. In recent years, many rhinoplasty surgeons have actually called to move away from the strict adherence to the neoclassical canon, advocating for a collaborative approach that factors in the patient’s goals, cultural background, and unique facial anatomy.
The face is one of the most intimate areas of the body, closely related to the way that we view ourselves and how we present ourselves to the world. In all of medicine, norms are necessary. By having a collective sense of what the average is, we are able to point out that which is diseased or aberrant. However, it is essential to carefully consider the provenance of our norms and what groups have been included and excluded in obtaining them. By predicating our operative standards of facial norms on idealized ancient Greek facial measurements, we send a message to members of minority communities that their appearance is incongruous with beauty standards. By developing normative lab values or treatment paradigms based on only a small cross section of society, we limit the generalizability of diagnostic and treatment tools. And by reinforcing these norms in our testing, we send the wrong message to clinicians and ultimately, patients.
As I mentioned up top, standardized testing is an important quality control metric to ensure trainees have obtained the baseline knowledge required to safely practice. And yet, it can always be improved. At an institutional level, we should continue to move away from testing information predicated on a biological basis of race rather than race as a proxy for a variety of social factors. And at an individual level, we should continue to think critically about where our specialty norms come from and whether they adequately represent what is in the patient’s best interest.
What pieces of outdated information have you encountered in your test prep? Share in the comments.
Marc Drake is a fifth-year resident in the Department of Otolaryngology and Communication Sciences at the Medical College of Wisconsin. His clinical interests include facial reconstruction, violence prevention, and the interplay between urban design and health care. Dr. Drake was a 2024–2025 Doximity Op-Med Fellow.
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