In the UK, new medical graduates are known as Pre-registration House Officers (PRHOs). Postgraduate Deans are responsible for the PRHO year and for the final certification of PRHOs to allow them to be fully registered by the GMC as medical practitioners. However, as much as appraisal of professional growth is central to PRHO training, they are in need of a robust assessment mechanism to detect, at an early stage, individuals with significant clinical and professional deficiencies. Documented, reliable and valid ongoing information on PRHO performance will provide information for early intervention and will establish 'hard' observable evidence, for certification decisions. Thus, an approach that links appraisal/assessment of professionalism and clinical skills to education is the way forward. This paper describes a new approach to appraisal/assessment of PRHOs, which is currently being piloted in a number of regions in Scotland. The conceptual paradigm was developed during the last three years as a proposal for a Scottish national PRHO reform. 'Grounded' qualitative studies were employed to explore trainees' and trainers' perceptions of the expected competences (outcomes) of PRHO performance for appraisal/assessment purpose. The GMC recommendations are reviewed in light of the study results. An assessment model emerged that links appraisal to education. PRHOs' cumulative performance is documented over one year of training resulting in diagnostic profiles that provide guidance for evaluation and training of PRHOs. Poor performers are flagged in the early stages of training, thus allowing early intervention. The feasibility and acceptance of the model by educators, the health system and PRHOs has yet to be established.