The Universal Subjective: Justification for using objective assessments

In Immanuel Kant’s 1790 treatise, The Critique of Judgement, the German philosopher writes of beauty, taste and aesthetic judgement, stating “As regards the agreeable, everyone concedes that this judgement, which he bases on a private feeling, and in which he declares that the object pleases him, is restricted to him personally.” This reminds me of the injustices of subjective assessments used in medical education. As is often the case, panels of experts or professorial staff provide subjective reviews of trainees during the course of traditional medical apprenticeships. Based on input from a variety of faculty members, trainees are deemed able or not able to perform procedures such as flexible bronchoscopy, with little if any objective evidence to support competent practice.

Furthermore, competency itself is rarely defined. Does competency imply technical skill, and if so, for what procedures exactly? Does it also include communicating bad news, informed consent, the ability to effectively employ universal precautions, the ability to troubleshoot, avoid, and treat complications, as well as the capacity to effectively interact with the bronchoscopy team? What about the ability to advocate for patient rights, communicate with a nursing team, or satisfactorily assess infection control and equipment sterilization/cleaning systems. Few institutions, and even fewer medical societies have written guidelines that clearly identify what is meant by procedural competency, and when they do, they are rarely accompanied by examples of objective assessment tools used to document levels of practice and competency itself.

Until very recently, therefore, the subjective assessment has been a cornerstone of medical teaching. Whether we like it or not, subjective assessments are important considerations related not only to how professors feel about their trainees, but also to how their presumably unbiased observations are used in the overall measure of a trainee’s ability to perform and practice medicine independently. I would argue, however, that beauty is in the eye of the beholder and that subjective assessments are too easily influenced by mood, character, personality, conventional wisdom, and other factors that may have little to do with a trainee’s ability to competently perform a medical procedure. Objective assessments, on the other hand, are reproducible, identify a trainee’s strengths and weaknesses, allow documentation of improvement along the learning curve, identify clear outcome measures, goals, and objectives, and also provide a starting point for objective feedback. In addition, objective measures provide a measure of the professor’s ability to teach effectively, forcing both institutions and medical societies to define competency, or at the least, a minimum standard toward which all practitioners can strive.

Perhaps that is a reason why medical societies and university-based teaching programs have been reluctant to introduce a battery of objective measures into their training curricula. After all, the number of issues raised by the formulation of an objective measure is enormous. Addressing issues such as how to provide remedial training, what to do in case information is poorly acquired, how to define a minimum standard, what to actually measure as a test of competency, who will do the paperwork and shoulder the administrative burdens related to documentation etc.… require manpower, expertise in educational philosophies, strict methodology, and an ability to persuade students, trainees, teachers, and administrators that such measures are an important part of medical training. While some might argue that such a task is Sisyphean in nature, I would argue it is simply Herculean, and that once initiated, will result in greater equality of practice among health care providers around the world, which ultimately will benefit patients everywhere.