By DR. LARA HAZELTON
Director, Academic Faculty Development, Dalhousie University Faculty of Medicine
How do we know when someone is excellent? In medical education, as in medical practice, excellence is often said to be the goal. Yet operationalizing the achievement of that goal can be difficult. We may have ideas about how the term can be applied in particular settings, but identifying and quantifying excellence in a systematic manner turns out to be surprisingly complex.
VanTassel-Baska (1997) defined excellence as “both the process of working toward an ideal and attainment of a consistently high level of performance.” This definition captures the dynamic nature of excellence and the concept of achievement, but it does not answer the question of what our ideals are, or what we consider high performance. High scores on examinations, the traditional means of identifying and rewarding excellence among medical students, are not always correlated with clinical practice. They are, however, more standardized than workplace-based assessments, and their appearance of objectivity may provide a sense of comfort in choosing who gets singled out for awards and scholarships.
One way to identify excellence is through norm referencing, where an individual’s performance is compared against an average, with the highest performers being considered excellent. Cognitive scientists tell us that we all have an instinctive tendency to make comparisons. Comparing one thing to another helps us to understand the differences and similarities between them, and can lead to judgements about which is better. The problem is that if overall performance in the group is poor, then even the top performers might not be excellent. Similarly, evaluations that ask if a student has met or exceeded expectations will not necessarily identify excellence if the expectations themselves are low.
In contrast to norm referencing, criterion referencing sets out specific requirements against which achievement is measured. In this model, it is theoretically possible for all members of a group to achieve excellence by meeting the criteria as defined. Medical education, especially competency-based medical education, utilizes criterion-referenced evaluation. If students are judged to have met objectives (or achieved competence) then they are permitted to advance to the next stage. However, some feel that merely meeting standards does not ensure excellence, especially if the standards are insufficiently rigorous.
In Britain, the 2007 Tooke Report into medical education found that over three-quarters of respondents aspired to clinical excellence, and not just meeting minimum standards. Still, it could be argued that the pursuit of excellence is a supererogatory act, one that goes beyond what duty requires. If a resident meets the minimum standards required for certification, is it reasonable to ask him or her to also try to be excellent – assuming we know what that means?
The concept of excellence is embedded in professional codes of ethics. The CanMEDS Framework includes, “Commitment to excellence in clinical practice and mastery of the discipline,” as part of the professional role. Strengthening our commitment to excellence in our own practice, and modelling it for our learners, is likely to be the most effective means we have for encouraging excellence in our learners.
Dr. Lara Hazelton is an associate professor with Dalhousie University's psychiatry department; Director of Academic Faculty Development with Dalhousie's Faculty of Medicine; and an attending physician in the Nova Scotia Health Authority's Central Zone.