We’ve spent years in the classroom. We’ve spent months in hospitals and clinics. We’re an amalgamation of experiences, from our first encounter that nudged us toward medicine to the patient we did our best to suture back together. But now, it’s 11 a.m. on a Wednesday, and there are three digits suddenly available that will determine the rest of your professional life.
Seeing my board score for the first time felt reductive. This number conveys nothing about the comfort I am able to give patients and their families; nothing about the trust I’ve built with every healthcare team I’ve had the privilege of working with. All it does is narrow my thinking into imagining what flavor of physician I am allowed to become. In that moment, I realized my primary goal over the past several months had become chasing a number rather than enriching myself to become the best future physician I could be. What did I really value, what made me pursue medicine in the first place?
While reading "The Score" by C. Thi Nguyen, I realized he went through an analogous experience, albeit in an entirely different discipline. When he began rock climbing, his initial goals were oriented toward elegance and the experience of movement. But once he learned that climbing routes have numerical difficulty grades, he found himself pursuing higher numbers rather than the form of the climb. A number that is supposed to be purely informational became the definition of success, even if it said nothing about what really mattered in the sport. I can’t help but notice that medical training is filled with similar numbers, and, like the climbing grade, they rarely stay the passive metrics they were meant to be. Scored systems can feel like games we have to play to get where we want to be.
Nguyen describes value capture, in which a person begins with a rich, nuanced value in some aspect, and then an institution provides an easier-to-understand, often quantified version of that value. Because the standardized version is easier to communicate, it eventually takes control of the individual’s decisions.
We see this happening in our own lives as medical students. Certain self-inquiries can be revealing. Are we working on becoming knowledgeable to become better clinicians or to achieve a higher exam score? Are we trying our best to be dependable on rotations to be an asset to the team, or to earn honors? Are we doing research to meaningfully contribute to the advancement of medical science, or to add more bullet points to our resumé? Are we looking for a career that is genuinely fulfilling, or are we trying to match into the most prestigious specialty available?
Examinations are meant to assess what we know, but they end up influencing what we study, what we neglect, and what we value in our educational experiences. When we get a preceptor who expects us to be in clinic for only half the day and use the other half to study, we feel relieved that we will have more time to prepare for exams. But I’d argue that any additional patient interaction would do more to make us better physicians in the future than any extra points on the test. After all, is real-world practice more similar to the living patient in front of you, or the fantasy one in the practice questions?
When we are continuously evaluated, we begin selecting behaviors for their visibility to our evaluators. In Nguyen’s words, “the score shapes the struggle.” Compare the readily apparent performance we put on for evaluators with the beauty of the process itself. We might not receive any formal recognition for helping a patient understand their treatment plan or for calling a family member with an update, even though these types of actions are central to the humanism required in medical care. We’ve all had patients tell us something like, “You’re going to be such a great doctor, I just know it,” or, “You’re the first person in a long while who has taken the time to really listen to me.” That kind of thing assures me that I am doing well and on the right path, even if it doesn’t end up on the evaluation form.
Even with their adverse effects, medical schools and residency programs do need methods of evaluation. Metrics are still useful for establishing minimum knowledge standards, and a licensing exam demonstrates that a student has met a certain level of understanding before being entrusted with patients' lives. Grades can be useful in identifying students who need support or in comparing performance across different training sites.
Nguyen offers a distinction between a game’s immediate goal and the player’s larger purpose. Often the goal is, nominally, to win, but the purpose is to enjoy yourself and your time with peers. For the game to function, we must temporarily submit to its rules and measures, but winning isn’t the ultimate measure of success. We can apply that lesson to the metrics that dictate our training as medical students. The goal is to pass the exam, the purpose is to become knowledgeable; the goal is a strong evaluation with honors, the purpose is to become a dependable clinician; the goal is to match into your chosen specialty, the purpose is to enter work you’ll find fulfilling in the long term.
Eventually, I closed my score report and moved on to the next patient. There were patients with questions to be answered about today’s procedure and families to update on the condition of their loved one. None of these moments will be reflected in any of the numbers used to assess my apptitude as a clincian, but these are the moments that seem to capture the true meaning and purpose of what I am doing better than any metric ever could.
What are some of the more meaningful ways you measure yourself in medicine? Share in the comments.
