Competency based postgraduate medical programmes are spreading fairly rapidly in response to the new demands of health care. In the past 10 years, Canada, the United States, the Netherlands, and the United Kingdom have introduced competency models and other countries are following.1^–5 These frameworks are valuable, as they renew our thinking about the qualities of doctors that really matter.

Paramount in these developments is the view that quality of training should be reflected in the quality of the outcome—that is, the performance of its graduates. As postgraduate training almost fully focuses on learning in practice, training and assessment moves around the top two levels of Miller's hierarchical framework for clinical assessment (figure).6 Knowledge and applied knowledge of residents may be interesting, but performance in practice is the real thing. The question is: How can we assess it?