Leadership in Medical Education: Destigmatize The Scarlet Letters of Assessment

By Michael Gisondi (@MikeGisondi)

In 1850, Nathanial Hawthorne published, The Scarlet Letter: A Romance, which tells the story of Hester Prynne and her sentencing in a 16th century Puritan trial. Required to wear a red letter “A” as she stood before her fellow townspeople, Hester becomes a lightning rod for questions of morality, sexuality, shame, guilt, and identity – both for the fictional characters and the reader.

If you weren’t assigned The Scarlet Letter in high school, you still had plenty of opportunities to learn about shame in medical school. Guilt and shame permeate the medical profession, especially during training.

The words guilt and shame are often paired together in casual conversation, but they are in fact, different terms.

  • Guilt is a painful feeling linked to one’s behaviors and actions, when they are compared to some higher standard of performance. “I feel so guilty because I wasn’t prepared for that procedure. I caused the patient unnecessary pain. You should have done the procedure instead of me.”
  • Shame is a similarly painful emotion, punctuated by burdensome self-loathing. Shame is about the individual, not just their actions. “I am so stupid. They should never have let me into medical school. Look what I did to that patient! I’m a failure… I’m ashamed of myself… and I am bad.”

Returning to high school for a moment… were you ever made to feel like an outsider? Maybe you were decidedly uncool, eating in a cafeteria full of cool kid tables? Or maybe you were the Prom Queen, who was also the smartest girl in school… which cafeteria table was yours?

The vast amount of clinical content to be mastered by our students is overwhelming – without guidance by their medical school professors, students may question their abilities and sense of belonging.

  • Belongingness is a social construct, reflecting one’s desire to be included, to be part of a group or community. “I answered every question wrong during rounds. Every question. And the other students on my team never make a mistake. I knew this would happen. Their parents are doctors and mine are not. I worried I wouldn’t fit in, and I am now convinced that I don’t belong here.”

Whether you felt comfortable on the first day of medical school, or not, shame finds us all at some point. Imposter syndrome – a shame variant, I contend – strikes everyone in training and affects even the most seasoned physicians throughout their medical practice.

  • Imposter syndrome is another painful self-reflection that stems from a sense of inadequacy and lack of abilities, despite contradictory evidence of success. “Yes, I somehow Matched to this competitive residency program, but I don’t belong here… I don’t deserve this opportunity. In my heart I know, my program director made a mistake.”

Without doubt, those students who struggle in medical school or residency bear the greatest burdens of shame. It is easy to connect the dots. Our assessment practices are assessments of learning.

  • Meet the standard? Congratulations, you are ‘competent’, you are ‘achieving your milestones’, you are ‘good enough.’
  • Fail? Then you bear the shame of the ‘incompetent’, those unfortunate souls who ‘aren’t on trackto graduate, who are ‘not in good standing’… [sigh]… who are ‘bad’. Hester Prynne.

In 2015, Dr. Damon Kuehl and I published an editorial entitled, “R & P: The Medical Education Scarlet Letters.” I credit Dr. Kuehl with this cheeky metaphor. R = Remediation. P = Probation.

Should you be the unfortunate, struggling resident who finds yourself on remediation or probation, you might feel very much like Hester Prynne. As evidence, our editorial commented on a study of program directors’ behaviors after placing a resident on remediation or probation: only 50% of program directors informed their faculty colleagues about residents on probation. Guilt about their decisions? Shame on behalf of their trainees? Or maybe, concern about stigma? Hester Prynne.

When to place a resident on remediation or probation was among the most difficult challenges that I faced as a residency program director. I worried about the implications of such weighty decisions. Stigma is real. So are guilt, shame, imposter syndrome, burnout, loss of agency, limited job opportunities, self-efficacy as a learner, and the risk of physician suicide. So is morale, among both the residents and faculty.

R and P feel like last resorts.

But why is the system designed so poorly? Can we not recognize the normal distribution of aptitude and achievement?

Image credit: Wikimedia Commons

Every so often – by the above graph, 2.2% of the time – we encounter the truly struggling medical student who requires a lot of help. It’s normal distribution, even among a population of talented individuals.

I challenge you to rethink your assessment processes, to be assessments for learning. I also challenge our accreditation bodies to offer meaningful help to us, the educators, as we redesign our assessment methods. Can we not be more prescriptive?

“Students who fail to achieve X Milestone often struggle with Y professional activities. We recommend the following evidence-based remediation plan for these students. Most students will complete this remediation plan in Z months.”

Could this be the New Normal?


About the Author: Michael A. Gisondi, MD is an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael currently holds a position as Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University.


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