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effectively support the learners’ overall professional development.
When training programs possess high degrees of psychological
safety, it can be the learner who performs the majority of the feedforward activity from one educational experience to the next. The
institution and program must prioritize psychological safety within
the clinical learning environment to effectively share information to
support learner progression. Assessment data should also be used to
evaluate and improve both the assessment program and curriculum
and identify and address structural bias, individual explicit and
implicit bias, and prejudice (see Chapter 18
on program evaluation).
Van der Vleuten, Schuwirth, Hauer, and their colleagues have laid
out the key principles that should guide the creation, development,
and ongoing continuous improvement of programmatic assessment,
summarized in Box 3.1
.
33–35
In addition, involvement of the learner is
essential, embracing a “nothing about me without me” mindset.
36
Box 3.1
Core Principles of Effective Programmatic
Assessment
• The training program has a centrally coordinated
master assessment plan that aligns with and
supports a curricular vision.
• Competence is specific, not generic. Assessment
programs must sample across different clinical
contexts longitudinally over training using multiple
assessors.
• Use of quantitative (numeric) scales is not better
than qualitative (words and narratives) data (see
Chapters 5 and 6). Qualitative assessment can
provide valuable information and insights. Since use
of rating scales involves translating observations
and/or questions into a numeric code, the numeric
code is only useful if it is an accurate translation of
developmental ability.
• Assessors must use credible clinical standards
based on the best available clinical and systems
science when assessing care provided to patients
and families.
• Validity ultimately resides in the users (e.g.,
• Learners should be
provided opportunities to
perform some of their own
assessments and also be
empowered to seek
assessment from trusted
faculty.
• Learners should have
ready access to
information-rich feedback
to promote self-regulated
learning. Learner access to
assessment information
supports transparency and
the learner’s agency
—“nothing about me
without me.”
36
• All assessments,
especially lower-stakes
assessments (i.e., formative
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faculty, CCCs) of an assessment instrument as
assessors are the primary source of variance.
Training and preparing assessors is necessary to
fully realize CBME’s potential and reduce the
harmful effects of bias.
• The assessment program must have a robust
system for collecting information that is feasible and
readily accessible to both learners and those
performing the assessments.
assessments for learning),
should always lead to
meaningful feedback and
coaching.
• All assessment programs
should provide learners
with advisors (see Fig. 3.2
)
who can serve as a
sounding board and trusted
partner in interpreting
(“sense making”) of
assessment data and
judgments.
• All assessment programs
must possess systematic
and personalized
remediation for the purpose
of supporting learners in
addressing and closing
competency gaps and
deficiencies.
• Coaching is essential to
facilitate effective use of
assessment data for
reflection and to plan
learning.
• Expert groups, such as
CCCs that use effective,
bias-free decision-making
practices, make decisions
regarding learner progress
and readiness for
advancement.
CBME, Competency-based medical education; CCCs, clinical competency committees.
Importance of Groups in Programmatic
Assessment
When groups use effective practices, they make better judgments.
37
Having CCCs make judgments about learner development is an
increasingly important design component of programmatic
assessment.
37,38
Well-designed group processes enhance educational
judgment by providing a mechanism for developing shared mental
models of competencies through faculty training in assessment (see
Chapter 16).31 Conversely, poorly designed or implemented group
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processes can worsen educational judgments. Importantly, bias can
be either mitigated or exacerbated by group process. A growing
body of research suggests that high-performing, diverse groups (e.g.,
groups that implement evidence-based effective team practices) are
more likely to make better decisions about learners and better
support learners’ professional development.37 Therefore group
membership, such as for CCCs, should be diverse to be most
effective. CCCs should use the science of effective group practice to
regularly review their performance as part of quality improvement,
including examining their assessments and judgments for evidence
of bias.37 Chapter 16 provides a wealth of information to guide the
creation, management, and continuous improvement of group
process and CCCs.
Importance of Longitudinal Design Thinking
in Programmatic Assessment
Given health professions education is an intensely developmental
process that occurs over time and a continuum of a career,
assessment programs must logically be longitudinal in design.35 Van
der Vleuten and colleagues nicely described this longitudinal process
(Fig. 3.3).
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FIG. 3.3 Model for programmatic assessment. (From van der Vleuten
CP, Schuwirth LW, Driessen EW, et al. A model for programmatic
assessment fit for purpose. Med Teach . 2012;34(3):205-214.
doi: 10.3109/0142159X.2012.652239 .)
There are several key concepts in this figure. First, the assessment
activities are aligned with the curricular activities: assessment drives
learning and learning drives the right type of assessment. For
example, imagine a primary care physician trainee learning to care
for patients with chronic conditions such as diabetes, hypertension,
congestive heart failure, and so forth. We now know from years of
research that effective care of chronic conditions requires a
coordinated effort among multiple health professionals (e.g., nurse
case managers, pharmacists, social work, etc.) working as an
interprofessional team.39 In addition, informed decision-making and
coproduction with patients and families is essential.39 Thus the
clinical curriculum (“learning”) must include all of these elements
and clinical experiences. The assessments should target these
competencies, and the best assessment approaches in this example
would include multiple-source feedback for interprofessional
abilities (see Chapter 12) and direct observation for the informed
decision-making abilities (see Chapter 5).
These assessments will accrue over time, especially direct
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observations that should occur multiple times with different patients
and contexts. At some juncture, usually prespecified as part of the
assessment program, all the assessment data are collated, analyzed,
and reviewed by a group such as a CCC to judge the learner’s
developmental trajectory and create an individualized learning plan
an advisor will use with the learner to plan (coproduce) the next
cycle of learning.
If this longitudinal, integrated process works effectively, the final
evaluation session will be mostly a quality assurance check to ensure
that the learner is truly ready to graduate from their current
program. As van der Vleuten points out, this final review is a
“heavy,” high-stakes summative entrustment decision (Fig. 3.4
). This
final judgment must have been preceded by many moments of
feedback with a learning coach/mentor during the entire training
program. An important principle is that the final decision should
never come as a surprise to the learner.
FIG. 3.4 Continuum of assessment stakes.
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Specific Opportunities to Improve
Programmatic Assessment
Gain Clarity Around the “Why” of
Assessment
Multiple factors, including the profound impact of the COVID-19
pandemic on UME and GME around the globe, have led to a healthy
reexamination of assessment practices. The medical education
community is realizing that we need more developmentally focused
assessment, grounded in clinical practice—especially toward the
latter stages of training in the health professions (see Chapter 1). A
developmental mindset requires significant rethinking of the
purpose of assessment to better support professional development,
feedback, and coaching.
8,9,40
This will require a greater focus on
workplace-based assessment (WBA) because, unlike other
assessments, WBAs can provide more timely, longitudinal feedback
and occur at the point of care with patients and families. Technology
is also enabling more efficient implementation of WBA with greater
ability to capture narrative assessment using natural language
processing (NLP) on smartphones.
41,42
Table 3.1 provides a list of the
“W’s” that programs should ask themselves about concerning their
assessment program.
Table 3.1
The 6 W’s of Assessment to Ensure Clarity of Purpose
The
W
Description
Why Why should the assessment be used? The purpose of the
assessment tool should be connected to a meaningful
educational outcome.
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Who Who should perform (e.g., observations) or administer the
assessment (e.g., exams)?
What What is the content or focus of the assessment tool (e.g., what
knowledge or skills will be ascertained)?
How How will the assessment be conducted and completed? This
should include details about assessor training.
When When and how often should an assessment tool should be
used?
Where Where should the assessment be applied? This includes the
setting where the assessment will be used (e.g., ambulatory
clinic, operating room, etc.).
Ensure Comprehensive and Fair Coverage of
All Core Competencies
No single assessment tool or approach can sufficiently judge and
support a learner’s professional development. Table 3.2 provides a
matrix and combination of approaches that can assess all six general
competencies currently used in the United States for GME and
continuous professional development. This matrix applies equally
well to other competency frameworks highlighted in Chapter 1.
Ideally, competency frameworks and programmatic assessment
should better align across the UME–GME continuum.
Table 3.2
Examples of Minimal Required Competency-Based Assessments and
Core Competencies
Competencies (US General Competency Framework)
Explanation of
Assessment
Medical
Knowledge
Patient
Care
Interpersonal
and
Communication
Skills
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Faculty
Assessments:
Observations
of patient,
family,
procedures,
and
interprofessional
team
interactions
Work-based
clinical
reasoning
Observation
with or
without
questions.
Singleencounter
work-based
assessment
tools (e.g.,
mini-clinical
evaluation
exercise) are
primarily
designed to
guide the
observation of
a clinical
encounter
between
learners and
patients.
X X X
Multisource
feedback
(including
interprofessional
team and
patients)
Combination
of
observations
made by the
assessor from
interactions
with the
learner that
are captured
through a
series of
questions (i.e.,
survey items)
using various
types of rating
scales with or
without
narrative
X X
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comments.
In-training,
licensing, and
certification
examination
Typically,
MCQs and
SAQs
X
Medical record
audit
Observation
through an
explicit
(structured) or
implicit
(unstructured)
interrogation
of a medical
record.
Structured
audits
typically
involve
extraction of
performance
measures (an
observation of
whether a
component of
care was
delivered or
not) that are
aggregated
into a score.
Unstructured
audits
typically
involve
judging the
quality of
medical
record
documentation
and
X
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description of
medical
interviews,
physical
exam,
counseling,
etc.
Individualized
learning plan
(not technically
an assessment,
but crucial in
development)
Reflective
practice is
now a
codified
subcompetency
in GME under
PBLIU and
the ability to
coconstruct an
ILP should be
a component
of reflective
practice.
Mastery-based
simulation for
procedures,
high-risk and
rare clinical
situations
An
observational
assessment
that can be
combined
with
questions
(checklists)
depending on
the purpose of
the
assessment.
SPs typically
convert their
observations
to ratings
using various
types of scales
with or
X X X
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