Intended for healthcare professionals

Clinical Review ABC of learning and teaching in medicine

Work based assessment

BMJ 2003; 326 doi: (Published 05 April 2003) Cite this as: BMJ 2003;326:753
  1. John J Norcini

    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.

    This article explains what is meant by work based assessment and presents a classification scheme for current methods

    Fig 1

    Miller's pyramid for assessing clinical competence


    Although the focus of this article is on practising doctors, work based assessment methods apply to medical students and trainees as well. These methods can be classified in many ways, but this article classifies them in two dimensions. The first dimension describes the basis for making judgments about the quality of performance. The second dimension is concerned with how data are collected.

    Classification for work based assessment methods

    Basis for judgment


    In judgments about the outcomes of their patients, the quality of a cardiologist, for example, might be judged by the mortality of his or her patients within 30 days of acute myocardial infarction. Historically, outcomes have been limited to mortality and morbidity, but in recent years the number of clinical end points has been expanded. Patients' satisfaction, functional status, cost effectiveness, and intermediate outcomes—for example, HbA1c and lipid concentrations for diabetic …

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