#KeyLIMEPodcast 263: This bugs me SO much…

Those in medical education know how important understanding learners’ internal states is : their ability to self-reflect, to be empathetic, to engage in professional identity formation.  This commentary, selected by Lara, asks the question, how can you measure a phenomenon like empathy when you can’t objectively observe it? Check out the podcast to hear the discussion!


KeyLIME Session 263

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Veen et. al., Knowledge, skills and beetles: respecting the privacy of private experiences in medical education.Perspect Med Educ. 2020 Apr;9(2):111-116.


Lara Varpio (@LaraVarpio)


  • This paper focuses on beetles – that is: the fuzzy, internal, private states and characteristics we expect medical learners to have.
  • If we can only see inside ourselves, inside our own boxes, then we only know what our own beetle looks like. This applies to things like empathy, professionalism, integrity, or professional identity formation. These are NOT skills, nor are they knowledge. They are that other, messy stuff we call attitudes or attributes.
  • Medical education is interested in understanding learners’ internal states—their ability to self-reflect, to be empathetic, to engage in professional identity formation. But these are internal states unique to the individual. We know these private, internal states exist and we know that our care professionals need to develop them—BUT we can not observe them. We can not measure them. Because there is no external direct referent to point to. I can observe and measure your suturing skills and assess that skill. I can not directly observe or measure your empathy. So how can I measure a phenomenon like empathy when I can’t objectively observe it?


  • We want to train empathetic and reflective clinicians who have integrity and embrace their status as a physician. So how do we do that? How do we know when someone is excelling or lacking in part of these important attributes?
  • So, what should we do? How do we get out of this contradiction of wanting physicians to master and embody attitudes and values, but we have no way of assessing if they actually have achieved that goal?

Key Points on the Methods


Key Outcomes

  • These authors suggest three questions that should come before we engage in any educational development:
    1. Do we want to assess this and if so why? Does the intended assessment truly contribute to the development of the competency?
    2. Is it possible to assess this?
    3. Which aspect of this phenomenon do we assess and how?
  • The authors suggest that it is time to consider engaging in subjective assessment – so instead of trying to generate objective assessments of a learners performance, a subjective assessment means that the assessor’s experience is a necessary part of the assessment. This is a phenomenological approach to assessment which means that the experience of the assessor is the criterion, NOT the objective assessment. It means using our subjective experience of watching a learner to know if my personal sense of integrity resonates with the way I see that learner engaging with patients with integrity.

Key Conclusions

  • The authors conclude: “The central conundrum is simply stated. If the condition for inclusion in the medical curriculum is that something is objectively measurable, then indeed beetles have no place in the curriculum, and we should focus only on knowledge and skills. Yet, we know that there are things (integrity, values, self-awareness, to name but a few) which matter profoundly but which cannot be clearly defined, let alone assessed.”

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