In 1990 psychologist George Miller proposed a framework for assessing clinical competence. At the lowest level of the pyramid is knowledge (knows), followed by competence (knows how), performance (shows how), and action (does). In this framework, Miller distinguished between “action” and the lower levels. “Action” focuses on what occurs in practice rather than what happens in an artificial testing situation. Work based methods of assessment target this highest level of the pyramid and collect information about doctors' performance in their normal practice. Other common methods of assessment, such as multiple choice questions, simulation tests, and objective structured clinical examinations (OSCEs) target the lower levels of the pyramid. Underlying this distinction is the sensible but still unproved assumption that assessments of actual practice are a much better reflection of routine performance than assessments done under test conditions.