Formative Assessment as Emotional Encounter: Professional Identity, Relational Practice, and the Affective Architecture of Critical Care Residency Training

To understand how a doctor becomes a doctor, one must look beyond the textbooks and the surgical skills. For decades, medical training has focused heavily on the mind: memorizing anatomy, mastering procedures, and learning to make logical decisions. It is often assumed that emotions are separate from this work, perhaps even a distraction that a good physician must learn to set aside. However, a growing body of research suggests that feelings are not just background noise; they are the very ground on which professional identity is built. When a student enters a high-stakes environment like an intensive care unit, they are not just learning to treat patients; they are learning who they are as a person in that role. The way they are treated by teachers and supervisors during these formative years shapes their ability to care for others, their sense of belonging, and their long-term well-being. If the emotional atmosphere of training is harsh or dismissive, it can damage a future doctor's capacity for empathy. If it is supportive and attentive, it can foster a deep, lasting commitment to the profession.

This reality is the focus of a new study conducted in a high-complexity hospital in Colombia, where researchers set out to understand the hidden emotional life of critical care residency training. The study involved forty-one people, including residents in training, their teachers, nurses, hospital leaders, and even former patients. Instead of simply asking how well the residents performed on tests, the researchers listened to their stories about how they felt during their training. They wanted to know how the daily interactions of learning and being evaluated shaped the residents' sense of self. The team found that the process of learning to be a doctor in the intensive care unit is not just a technical education; it is an emotional journey where every conversation, every grade, and every moment of feedback carries a heavy weight.

The researchers discovered that emotional vulnerability is not a sign of weakness in these trainees, but a structural part of the job. In this specific training program, residents enter the intensive care unit immediately after finishing medical school, without having specialized in other areas first. They must learn complex technical skills, manage their own intense emotions, and figure out their professional identity all at once. The study found that this creates a state of constant disorientation. One resident described the first year and a half as a time of feeling disconnected, unsure if they were in the right place. Another noted that the culture often expects them to simply keep going, without ever being taught how to handle what they feel. The prevailing idea of "resilience"—the ability to bounce back from stress—was rejected by the participants. Instead, they described their experience as a daily act of resistance, a struggle to survive rather than a natural adaptation. They felt that the system expected them to manage their distress in silence, rather than acknowledging it as a normal part of the learning process.

A central finding of the study is that professional identity is formed not by lectures or written rules, but by what residents see and feel in their daily interactions. The researchers found that residents learn what it means to be a doctor by watching their teachers. If a teacher models kindness, transparency, and genuine care, the resident absorbs those values. If a teacher is cold, dismissive, or cruel, the resident learns that this is how a doctor behaves. This process is so powerful that it can work in reverse: a resident might see a teacher who lacks empathy and decide, "I will never be like that." However, the study also highlighted a dangerous side effect of this proximity to suffering. Without institutional support, the constant exposure to death and pain can lead to a gradual hardening of the heart, a desensitization where the human connection required for good care begins to fade. The teachers confirmed this, noting that when medicine is taught through dominance rather than care, residents begin to copy those behaviors, creating barriers between themselves and the patients they are meant to help.

The study also revealed that empathy is not a skill that lives inside a single person, waiting to be switched on. Instead, the researchers found that empathy circulates through the entire hospital environment like a current. It spreads from the doctors to the nurses, and from the staff to the patients and their families. When the atmosphere is respectful and caring, that feeling extends naturally to everyone involved. Conversely, when the environment is cold, the ability to connect with others withers. One resident explained that in services where the treatment of staff works well, they automatically begin to treat patients and families in the same way. It is something that spreads without anyone having to plan it. This means that trying to teach empathy through a single class or a checklist is insufficient; the entire culture of the training environment must support it.

Perhaps the most charged aspect of this training is the moment of assessment, when a teacher evaluates a resident's performance. The study found that these moments are not just about checking a box or assigning a grade; they are emotional encounters that can either affirm a resident's identity or damage it. When feedback is delivered publicly, without prior warning, or with a tone of contempt, it can leave a resident feeling destroyed and demotivated. One resident recalled being told they were a disappointment in front of others, a moment that left them feeling broken as a person. Another described having grades changed after the fact, based on criteria they had never been told about. These experiences create a culture of fear, where assessment is seen as something to be avoided rather than a tool for learning. The researchers noted that when assessment is treated as a one-way judgment rather than a dialogue, it strips the resident of their agency and makes them feel like an object rather than a developing professional.

The study concludes that the well-being of the resident is not a personal issue to be solved by the individual, but a structural requirement for ethical care. When the emotional needs of trainees are ignored, the consequences extend beyond their own suffering. It affects the quality of care they provide and the humanistic sensibilities they need to be good doctors. The researchers argue that the current focus on "resilience" is a mistake because it places the burden of coping on the student, ignoring the toxic conditions that cause the stress in the first place. Instead, they propose that training programs must recognize the vulnerability of the learner as a normal part of the process. By designing assessment and feedback systems that are transparent, dialogic, and grounded in care, institutions can turn these emotional encounters into opportunities for growth.

The authors suggest that the way we evaluate doctors in training needs a fundamental shift. It is not enough to check if a student knows the right answer; we must also look at how the process of evaluation makes them feel and who they are becoming in the process. The study proposes a concept called "affective architecture," which refers to the emotional structure of the learning environment. Just as a building has a physical structure that supports or hinders movement, the emotional structure of a training program supports or hinders the development of a professional identity. If this architecture is built on respect, safety, and mutual recognition, it allows residents to grow into compassionate, capable physicians. If it is built on fear, shame, and silence, it damages their ability to connect with others. The study does not claim to have solved all the problems of medical education, but it offers a clear path forward: treating the emotional and relational aspects of training not as a soft add-on, but as the foundation of professional formation. In the end, the most rigorous step a training program can take is to treat the act of teaching and evaluating as an act of care.