Secondary Logo

Journal Logo


Reconceptualizing Variable Rater Assessments as Both an Educational and Clinical Care Problem

Kogan, Jennifer R., MD; Conforti, Lisa N., MPH; Iobst, William F., MD; Holmboe, Eric S., MD

Author Information
doi: 10.1097/ACM.0000000000000221
  • Free


The public is calling for our health care system, and the medical education system embedded within it, to be accountable for ensuring high-quality, safe, effective, patient-centered care. Clinician educators’ assessments of and feedback to trainees about their developing clinical skills are particularly important as medical education shifts to a competency-based training paradigm.1,2 However, there is substantial variability in the accuracy, reliability, and validity of assessments generated through direct observation of trainees with patients.3–5 These difficulties have been treated primarily as a rater cognition problem, focusing on the inability of the assessor to consistently make reliable and valid assessments of the trainee.6–8

We wrote this article to reconceptualize the rater cognition problem as both an educational and a clinical care problem. We will propose that the variable quality of faculty assessments is more than a psychometric predicament but is also a problem that has implications for decisions regarding trainee supervision and quality of care. We will highlight how valid assessments of trainees (most often residents and fellows but sometimes medical students also) at the point of care are fundamental to achieving high-quality patient care. We will argue that if an assessment tool does not take into consideration the outcome of safe, effective, patient-centered care, the utility of that assessment is null and void. We will propose that the frame of reference and anchor of workplace-based assessments be the ability to provide safe, effective, patient-centered care. We will offer an equation, which we call the Accountable Assessment for Quality Care and Supervision (AAQCS) equation, to remind faculty that supervision is a dynamic, complex process essential for patients to receive high-quality care. We will recommend aligning rater training with programs that simultaneously allow clinical supervisors to practice the patient care and communication skills underpinning high-quality care. Finally, we will argue for the indispensable role of the clinician educator in trainee assessment.


After the first 18 to 24 months of medical school, physicians’ training occurs primarily through clinical experiences in which trainees deliver patient care under the supervision of more experienced physicians.9 Trainees begin as novices and, through clinical encounters and structured, supervised educational experiences, practice, acquire, and ultimately apply competencies in the care of patients. The ultimate goal is for trainees to achieve the competence necessary to enter practice as unsupervised professionals. Clinical supervision provides monitoring, guidance, and feedback about skill development in the context of the trainee’s care of patients.10 In 2008, the Institute of Medicine (IOM) highlighted the importance of supervision and called for closer supervision of trainees.11 The intent was to reduce errors, lower patient mortality, and improve quality of care while enhancing residents’ education.11

During training, learners ideally should move through graduated levels of supervision based on their ability to care for patients, and the intensity of supervision should be informed by valid workplace-based assessment. Workplace-based assessments are conducted in authentic situations (i.e., day-to-day practice) and evaluate multiple, essential competencies in an integrated, simultaneous fashion.7 Direct observation of real-life patient encounters (e.g., watching a resident with a patient) is one of the primary mechanisms by which to collect information about trainees’ skills.7,8 It also provides essential content and context for feedback about clinical skills.12

Workplace-based assessments are partic ularly important given the shift toward competency-based medical education in which core competencies are articulated and subsequently measured.2 A key impetus for competency-based education is the public’s calls for physician account ability, improved health care quality, and enhanced supervision and assess ment of trainees.2,5,13 Foundational to competency-based education are multiple formative assessments of trainees, which inform evaluation and learning.1

Issues Associated With Workplace-Based Assessment

Despite their importance, workplace-based assessments are beset with validity concerns.3,4 A primary issue is high interassessor (i.e., faculty) variability of scores, leading to poor interrater reliability.14,15 Assessors themselves explain as much as 40% of this variability.16–19 Rating errors stem from leniency, stringency, halo, and central tendency effects, as well as anchoring and contrast bias.20–22 The implication of these errors and biases is that different raters rate the same encounter differently5,23 and make different pass/fail decisions.24

The etiology of high interrater variability is likely multifactorial. Multiple complex social and psychological processes are involved when faculty make judgments about a trainee.6,7,15 First, raters use different frames of reference (i.e., what they compare the trainee’s behaviors against), with themselves being the most common.25 For example, faculty benchmark residents’ performance to their own practice styles. Comparing a resident’s performance with that of residents at a similar training level is also common and becomes problematic if faculty are uncertain about what skills should be expected at a particular stage of training, or what constitutes competence.21,25 Assessment criteria often develop experientially over time, may be weighted differently by different assessors, and may uniquely focus on variable and different aspects of performance.21 Consequently, the aspects of performance that assessors regard as useful for determining quality are inconsistent between assessors.21,25

When observing trainees with patients, faculty also make many inferences (deriving what seem to be logical conclusions from premises assumed to be true).20,25 For example, imagine that a resident, while standing with crossed arms, delivers bad news to a patient. The faculty member may infer from this posture that the resident lacks empathy and humanism. However, alternative explanations are possible (e.g., the trainee has never delivered bad news and is uncomfortable). Faculty make inferences about residents’ funds of knowledge, competence, work ethics, prior experience, emotions, intentions, personalities, and even culture.20,25 Although making inferences is unavoid able and not necessarily bad, this becomes problematic when inferences are not recognized and validated.25 Therefore, inference in direct observation further influences the validity of assessment.

A third potential source of high interrater variability might relate to the clinical skills of faculty. Supervising physicians’ clinical skills may influence how they rate residents in the clinical setting.20,25,26 The clinical skills of faculty are variable and sometimes deficient.27–30 If quality medical care underpins clinical skills assessment, faculty must know and be able to accurately identify and assess evidence-based skills that characterize or promote such care. However, many of these skills, such as patient-centered communication, are minimally taught or emphasized during medical school and postgraduate training.31 Many faculty (save recent medical school graduates or those seeking additional training) have not received formal training in important communication skills such as delivering bad news, using empathy as a communication tool, and developing patient partnerships.32 Additionally, few opportunities exist for practicing physicians to learn and intentionally practice such skills.31

Historically, various approaches have been used to tackle the quandary of idiosyncratic ratings and high interrater variability. A common strategy has been to try to “fix the rating form.”33,34 A second strategy, rater training, has had minimal impact.35,36 A third strategy has used statistical methods (sampling across contexts and assessors) to ensure the reproducibility or generalizability of assessments.8 Practically, this entails observing the trainee in multiple clinical encounters over time using multiple different observers; a reliable, valid assessment of the trainee can be made with seven to nine assessments.37

It’s Not Just a Rating Problem

To date, high interrater variability has primarily been treated as a rater cognition or psychometric problem that affects trainee assessment.6–8 We submit that there is another stakeholder missing from the discussion of ratings: the patient.

A patient is not just a “variable” in a multivariable psychometric equation. A clinical supervisor must be able to accu rately observe how a trainee provides care during a patient encounter to ensure that the patient receives high-quality care in that care episode. Accurate observation means identifying the presence or absence of appropriate clinical skills and important patient outcomes. For example, an attending observing a resident counseling a patient about starting a medication must correctly ascertain whether the elements of patient-centered, informed decision making are present and whether the patient receives the care he or she needs.38 If all this does not occur, the attending may have failed to appropriately supplement the resident’s clinical skills to ensure that the patient receives the needed care in that encounter. So while a composite judgment of a trainee across encounters and assessors helps to achieve “good” psychometric assessment criteria of the trainee, it fails to address the ability of a clinical supervisor to assess effective patient care in the context of a single clinical encounter or across encounters. Therefore, a rating does not simply represent how well (or not) the trainee did. Rather, in our example, the observations that informed the judgment and rating should also direct the attending’s decision making about the kind of care that the attending must contribute to the patient encounter. Observation, therefore, informs decisions about immediate and future supervision.

Clinical supervisors must balance trainee independence required for learning with adequate supervision for patient safety.39 Negotiating this balance requires point-of-care competence assessment—that is, assessment occurring at the time of and in the setting of clinical care.39 Faculty observation of, for example, a resident–patient interaction informs decisions about supervision—not just for that particular encounter but also for encounters going forward.39 An important trigger for more intensive oversight or supervision is the concern about a resident’s competence or ability to effectively handle a specific clinical situation.40 Therefore, if an attending inaccurately identifies how well or poorly the resident carries out patient care, the attending may not make high-quality decisions about the resident’s ability to give unsupervised care in the future.

Accurate assessment is, therefore, fundamental to high-quality decisions about supervision. Interrater variability is no longer just a rater cognition problem affecting the assessment of trainees. It risks being a clinical care problem for patients. Herein lies the conundrum. From a psychometric viewpoint, educators know that decisions about a trainee should not be based on a single observation, and many training programs have systems in place to obtain multiple evaluations per trainee. However, faculty must be able to use a single observation to determine what care they need to provide to a patient in a given encounter. A single observation may also inform decisions about the intensity of ongoing supervision (keeping in mind case and context specificity). Errors in these assessments run the risk that a patient, or future patients, will receive inadequate care.

In our current educational system, faculty cannot observe all patient encounters in their entirety. Faculty rely heavily on trainees’ self-assessments for when they need to ask for additional help.40 This implies that trainees can know the limits of their abilities or can self-monitor in action.41 Self-assessments can be informed by accurate, valid, external feedback.42 If faculty make low-quality observations of trainees, the subsequent feedback to the trainee will be of low utility. Consequently, trainees do not obtain the external feedback that could better guide their requests for future supervision. This further jeopardizes the quality of patient care that the trainee provides in the future. The end result is a continual dysfunctional cycle of poor education and poor clinical care.

Solutions Going Forward

We propose three potential strategies to address this rating conundrum: (1) redefine workplace-based assessments’ frame of reference and rating scale anchors, (2) link the focus of in-training assessment with the assessment of high-quality care to inform supervision decisions, and (3) align rater training with clinical skills education—that is, by having programs that simultaneously allow clinical supervisors to learn and practice clinical skills that underpin high-quality care.

Redefine workplace-based assessments’ frame-of-reference and rating scale anchors

Many workplace-based assessment tools have not articulated what frame of reference (e.g., the standard by which to assess performance, such as criterion based or normative) should be used when assessing trainees. Most tools have anchors such as “unsatisfactory,” “satisfactory,” or “superior,” or “doesn’t meet expectations,” “meets expectations,” and “exceeds expectations,” with little guidance as to what informs that decision.3,4 Furthermore, one might ask, “Satisfactory for whom?

If quality clinical care is the assessment end point, then assessment of trainees should be based on those competencies needed to achieve high-quality care, thereby enabling medical educators to prepare trainees for independent practice.43 Therefore, we propose that the education community strive to make the frame of reference of workplace-based assessments the patient rather than the more commonly used frames of reference such as self, trainee level, or a gestalt or gut feeling.25

In Crossing the Quality Chasm: A New Health System for the 21st Century,44 the IOM articulated the six aims of quality in medical care: it should be safe, effective, efficient, patient centered, timely, and equitable. Reconceptualizing medical education from the desired end point of clinical care quality situates patient care at the center of the assessment discussion rather than making it a peripheral, discretionary topic.43,45,46 Therefore, we propose that the definition of satisfactory when doing workplace-based assessments be what is required to achieve high-quality patient care (as defined by the IOM and evidence-based best practices) in the unsupervised setting. For example, if the nine-point version of the mini-CEX was used,23 “5,” which is defined as “satisfactory,” would be synonymous with “competent care.” This would be the minimal floor for any patient cared for in a training setting. In other words, the scale’s midpoint, by definition, must equate to the trainee’s ability to provide safe, effective, patient-centered care in independent practice.

This reconceptualization represents a significant shift in our training culture. Although faculty may believe that they take these domains into consideration, rater assessment research suggests otherwise (ratings are idiosyncratic, normative, inflated, and fail to align with criterion-referenced quality of care).21,25,47 For example, our experience in leading faculty development sessions on trainee assessment revealed that many faculty see patient-centered skills as “icing on the cake” rather than as necessary for competent care, despite the fact that these skills are linked to health outcomes.48

Redefining satisfactory aligns with the transition toward criterion-based competency assessment.49 Competency-based assessment tools are emerging in which the rating system is based on the trainee’s readiness for safe, independent practice.50 Aligning rating scales to the construct of clinical independence, or entrustability, may improve score reliability and assessor discrimination, reduce assessor disagreement, and be more cognitively aligned with the reality map of the assessors (i.e., resonate with raters’ experiences of what they can assess).51 Knowing whether trainees are achieving important developmental milestones on time is clearly important. However, by consistently applying the lens of high-quality patient care, we also keep the focus on what is most affected by their competencies: the patient.

What are potential implications for using this frame of reference (the patient) and this anchor (satisfactory is the ability to provide competent care unsu pervised)? Many trainees would be rated “unsatisfactory,” unlike the situation now, where grade inflation is endemic.52 Both faculty and trainees would need to recognize that many ratings would fall in the lower end of the scale. This would necessitate a shift in the educational culture of what unsatisfactory means—no small feat. Second, educators or trainees might see “competent” as the goal, rather than proficiency, expertise, or mastery. Although “competent” may anchor the midpoint of any scale, we believe it is important to emphasize that being competent is not the aspiration, it is the floor. Articulating and defining aspirational, superior clinical skills will be necessary. For example, “superior” might reflect proficient, expert performance defined as intuitive clinical care and fluid performance that happens unconsciously and automatically, no longer depending on explicit knowledge.53

Link in-training assessment with the assessment of high-quality care to inform supervision decisions

The utility elements of assessments are validity, reliability, educational impact, practicability, acceptability, and cost-effectiveness,54 and the utility value of an assessment becomes null and void if any of the utility factors become zero.54,55 For example, an assessment would not have utility if it had no validity, even if there was good reliability, impact, practicability, acceptability, and cost-effectiveness.

We suggest that there is a missing factor in the current utility equation: the ability to assess the patient care outcome. If an assessment tool fails to consider the outcome of safe, effective, patient-centered care, we submit that the utility index for that assessment tool is also null and void. Although validity has been framed in terms of quality of patient care,56 that framing does not necessarily ensure that the patient receives good care. The flaw in previous conceptions of assessment is that the patient is treated only as a contextual variable, something to adjust for. We believe that an assessment tool cannot be agnostic to what happens to the patient. The patient, and the care that the patient receives, must be part of what is assessed in an observation.

We believe that medical educators can improve the validity of a tool’s assess ments while concomitantly ensuring safe, effective, patient-centered care by changing the frame of reference and accountability goals of the assessment. Although assessment is integral to learning,57 assessment tools must help clinical supervisors determine what a trainee can do independently. Supervisors can then use the assessment to inform what they must contribute to the care of the patient and in what capacity.

To highlight this idea conceptually, we developed the AAQCS equation (portrayed in Figure 1). Modeled on the utility index equation,54 the AAQCS underscores that what a trainee does (which is a function of that individual’s level of competence in a particular context) combined with an appropriate level of supervision (a function of the supervisor’s competence in context) must equate to safe, effective, patient-centered care. The “equation” is not something that is mathematically computed into a “score” but, instead, exemplifies that it is the interaction between trainee performance and supervision that produces, or ensures, high-quality patient care. A faculty member doing workplace-based assessment often dually serves as an assessor of a trainee and as the clinical supervisor responsible for the patient’s care. Anchoring assessment tools in high-quality care (defined as safe, effective, patient centered) reminds faculty who supervise trainees that their assessments reflect both the care that a trainee is independently able to provide the patient in a particular encounter and the quality of the care rendered. If care does not meet the standard of satisfactory (i.e., safe, effective, patient centered), faculty would be prompted to contribute to the encounter so that the care delivered rises to the minimal standard of competent (and hopefully aspirational) care. The AAQCS could also guide trainees’ self-assessment in action41 and clarify the standards against which they should be interpreting and judging their performance.42

Figure 1
Figure 1:
A graphic portrayal of the Accountable Assessment for Quality Care and Supervision equation (AAQCS) developed by the authors. The AAQCS underscores that what a trainee does (which is a function of that individual’s level of competence in a particular context) combined with an appropriate level of supervision (a function of the supervisor’s competence in context) must equate to safe, effective, patient-centered care. The “equation” is not something that is mathematically computed into a “score” but, instead, exemplifies that it is the interaction between trainee performance and supervision, as described above, that produces, or ensures, high-quality patient care. The purpose of the equation is to remind faculty that supervision is a dynamic, complex process essential for patients to receive high-quality care.

Clinical supervisors need to determine whether a resident can be entrusted with the tasks or activities critical to the profession.58 Currently, the intensity of clinical supervision is predominantly a “one size fits all” approach using the trainee’s training level or time as a proxy for competence.59 Often, on the basis of this assumption, faculty assign tasks at higher levels of responsibility than they believe suitable.60 For example, in U.S. outpatient continuity clinics, attending physicians are required to see residents’ patients prior to the conclusion of the patient’s office visit only for the first six months of residents’ training.61 However, this Medicare time policy is often discordant with residents’ actual achievement of the expected milestones that would allow less direct supervision after six months of training.62 Not all residents reach the same level of competence in all activities at exactly the same time, and not all are ready for indirect supervision after six months of training. When satisfactory is defined as the ability to provide high-quality care unsupervised, there is an inherent shift to deliberate, competency-based, informed supervision. The intensity of supervision is then grounded in the trainee’s skill level in a given clinical context.63,64

To implement such an approach will be daunting, yet doing so is imperative, given calls for public accountability. Because direct observation is infrequent, strategies ensuring patient safety in nonobserved encounters are needed. Developing a method for prioritizing the many different assessments/observations that could be performed to evaluate trainee competence is essential.65 Preferentially focusing observation early or when new skills are expected—for example, with simulation—could provide a realistic understanding of trainee skills.66,67 Given the discontinuity in clinical training,68 enhanced commu nication about learners’ skills has greater importance. For trainees, instilling a culture that promotes them to self-monitor and empowers them to request direct observation is needed.69

Align rater training with clinical skills education

If we want to train learners to be compe tent in providing high-quality care, faculty must be familiar with and trained in the requisite skills. As previously described, faculty frequently use themselves as a frame of reference when assessing residents.25 This is problematic if the faculty are not providing high-quality care.27–30 Therefore, many practicing physicians who supervise and assess trainees will need to improve or learn new clinical skills and practice them to reach proficiency.32

We have a unique opportunity to leverage the rater assessment problem by providing opportunities for clinical supervisors to learn and/or practice the very skills they are assessing. For example, there are best practices for patient-centered communication,70 informed decision making,38 breaking bad news,71 motivational interviewing,72 the evidence-based physical exam,73 effective use of the electronic medical record during a patient visit,74 and assessment of the geriatric patient.75,76 Reviewing and practicing these frameworks with faculty may provide an opportunity to not only define best practices but also to raise the floor for the care we provide. How to best accomplish this remains uncertain, but it would inevitably require a national faculty development curriculum.32

A Fundamental Shift Is Needed in Trainee Assessment

To be professionally accountable and attain the public’s trust, the onus is on us, as medical educators, to make good assessment decisions. The interrater variability of work-based assessments is not just an educational issue but also a patient care and safety issue. Medical education and health care delivery are intertwined. As such, part of the evaluation of trainees should consider the quality of patient care.77

When embedded in patient care, direct observation is still one of the best methods to assess how trainees integrate multiple skills in the real-world setting. However, its effectiveness is profoundly dependent on the faculty members’ skills. Done well, direct observation can be a quality improvement intervention for both the trainee and the patient. When observation is grounded in concepts of high-quality care, there is the potential to improve the trainee’s skills and competence (i.e., to catalyze the trainee’s additional learning). Simultaneously, identifying gaps in the trainee’s ability to provide safe, effective, patient-centered care informs decisions regarding supervision and entrustment, which can influence patient safety.

Now is the time to elevate direct observation from trainee assessment alone to trainee assessment that improves the quality of care patients receive in real time. Doing so offers opportunities to realize improved patient safety and decreased costs. We recognize this is a potentially controversial, fundamental shift in how assessment is currently conceptualized. Yet, there are real costs for not adopting this conceptualization of assessment. This approach will require faculty development—both for developing teaching skills and perhaps learning or refreshing clinical skills and best clinical practices.

Trainee assessment, clinical care super vision, and faculty members’ own clinical skills are inextricably linked to the process of ensuring high-quality patient care in the training environment. These interrelationships reinforce the essential and indispensable role of clinical faculty in the training and patient care missions. Nonphysicians can assess trainees’ skills, but they cannot provide clinical supervision. Intrinsically, clinician educators are fundamental to workplace-based assessment because they can be held accountable to ensuring that an individual patient and the population of patients that the trainee will see in the future receive high-quality care. Clinician educators are vital because they can bridge potential gaps in care, thereby elevating care quality. Without outstanding, capable clinicians who are also exceptional educators, our medical education system will fail to produce physicians who will meet the needs of our society. Now is the time to ensure that our health care and medical education systems support clinician educators to acquire the assessment and clinical skills they need to ensure that outcome.


1. Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: A systematic review of published definitions. Med Teach. 2010;32:631–637
2. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366:1051–1056
3. Kogan JR, Holmboe ES, Hauer KE. Tools for direct observation and assessment of clinical skills of medical trainees: A systematic review. JAMA. 2009;302:1316–1326
4. Pelgrim EA, Kramer AW, Mokkink HG, van den Elsen L, Grol RP, van der Vleuten CP. In-training assessment using direct observation of single-patient encounters: A literature review. Adv Health Sci Educ Theory Pract. 2011;16:131–142
5. Norcini JJ. Current perspectives in assessment: The assessment of performance at work. Med Educ. 2005;39:880–889
6. Gingerich A, Regehr G, Eva KW. Rater-based assessments as social judgments: Rethinking the etiology of rater errors. Acad Med. 2011;86(10 suppl):S1–S7
7. Govaerts MJ, van der Vleuten CP, Schuwirth LW, Muijtjens AM. Broadening perspectives on clinical performance assessment: Rethinking the nature of in-training assessment. Adv Health Sci Educ Theory Pract. 2007;12:239–260
8. van der Vleuten CP, Schuwirth LW. Assessing professional competence: From methods to programmes. Med Educ. 2005;39:309–317
9. Ramani S, Leinster S. AMEE guide no. 34: Teaching in the clinical environment. Med Teach. 2008;30:347–364
10. Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: A literature review. Med Educ. 2000;34:827–840
11. Rowe JW chairInstitute of Medicine Committee on the Future Health Care Workforce for Older Americans. Retooling for an Aging America: Building the Health Care Workforce. 2008 Washington, DC National Academies Press
12. Pelgrim EA, Kramer AW, Mokkink HG, van der Vleuten CP. The process of feedback in workplace-based assessment: Organisation, delivery, continuity. Med Educ. 2012;46:604–612
13. Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32:676–682
14. Albanese MA. Challenges in using rater judgements in medical education. J Eval Clin Pract. 2000;6:305–319
15. Williams RG, Klamen DA, McGaghie WC. Cognitive, social and environmental sources of bias in clinical performance ratings. Teach Learn Med. 2003;15:270–292
16. Alves de Lima A, Conde D, Costabel J, Corso J, van der Vleuten C. A laboratory study on the reliability estimations of the mini-CEX. Adv Health Sci Educ Theory Pract. 2013;18:5–13
17. Margolis MJ, Clauser BE, Cuddy MM, et al. Use of the mini-clinical evaluation exercise to rate examinee performance on a multiple-station clinical skills examination: a validity study. Acad Med. 2006;81(10 suppl):S56–S60
18. Wilkinson JR, Crossley JG, Wragg A, Mills P, Cowan G, Wade W. Implementing workplace-based assessment across the medical specialties in the United Kingdom. Med Educ. 2008;42:364–373
19. Weller JM, Jolly B, Misur MP, et al. Mini-clinical evaluation exercise in anaesthesia training. Br J Anaesth. 2009;102:633–641
20. Govaerts MJ, Schuwirth LW, Van der Vleuten CP, Muijtjens AM. Workplace-based assessment: Effects of rater expertise. Adv Health Sci Educ Theory Pract. 2011;16:151–165
21. Yeates P, O’Neill P, Mann K, Eva K. Seeing the same thing differently: Mechanisms that contribute to assessor differences in directly-observed performance assessments. Adv Health Sci Educ Theory Pract. 2013;18:325–341
22. Yeates P, O’Neill P, Mann K, Eva KW. Effect of exposure to good vs poor medical trainee performance on attending physician ratings of subsequent performances. JAMA. 2012;308:2226–2232
23. Holmboe ES, Huot S, Chung J, Norcini J, Hawkins RE. Construct validity of the miniclinical evaluation exercise (miniCEX). Acad Med. 2003;78:826–830
24. Schuh LA, London Z, Neel R, et al. Education research: Bias and poor interrater reliability in evaluating the neurology clinical skills examination. Neurology. 2009;73:904–908
25. Kogan JR, Conforti L, Bernabeo E, Iobst W, Holmboe E. Opening the black box of clinical skills assessment via observation: A conceptual model. Med Educ. 2011;45:1048–1060
26. Kogan JR, Hess BJ, Conforti LN, Holmboe ES. What drives faculty ratings of residents’ clinical skills? The impact of faculty’s own clinical skills. Acad Med. 2010;85(10 suppl):S25–S28
27. Ramsey PG, Wenrich MD, Carline JD, Inui TS, Larson EB, LoGerfo JP. Use of peer ratings to evaluate physician performance. JAMA. 1993;269:1655–1660
28. Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA. 1995;274:1380–1382
29. Vukanovic-Criley JM, Criley S, Warde CM, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: A multicenter study. Arch Intern Med. 2006;166:610–616
30. Braddock CH 3rd, Fihn SD, Levinson W, Jonsen AR, Pearlman RA. How doctors and patients discuss routine clinical decisions. Informed decision making in the outpatient setting. J Gen Intern Med. 1997;12:339–345
31. Levinson W. Patient-centred communication: A sophisticated procedure. BMJ Qual Saf. 2011;20:823–825
32. Frankel RM, Eddins-Folensbee F, Inui TS. Crossing the patient-centered divide: Transforming health care quality through enhanced faculty development. Acad Med. 2011;86:445–452
33. Donato AA, Pangaro L, Smith C, et al. Evaluation of a novel assessment form for observing medical residents: A randomised, controlled trial. Med Educ. 2008;42:1234–1242
34. Cook DA, Beckman TJ. Does scale length matter? A comparison of nine- versus five-point rating scales for the mini-CEX. Adv Health Sci Educ Theory Pract. 2009;14:655–664
35. Holmboe ES, Hawkins RE, Huot SJ. Effects of training in direct observation of medical residents’ clinical competence: A randomized trial. Ann Intern Med. 2004;140:874–881
36. Cook DA, Dupras DM, Beckman TJ, Thomas KG, Pankratz VS. Effect of rater training on reliability and accuracy of mini-CEX scores: A randomized, controlled trial. J Gen Intern Med. 2009;24:74–79
37. Moonen-van Loon JM, Overeem K, Donkers HH, van der Vleuten CP, Driessen EW. Composite reliability of a workplace-based assessment toolbox for postgraduate medical education. Adv Health Sci Educ Theory Pract. 2013;18:1087–1102
38. Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: Time to get back to basics. JAMA. 1999;282:2313–2320
39. Kennedy TJ, Regehr G, Baker GR, Lingard L. Point-of-care assessment of medical trainee competence for independent clinical work. Acad Med. 2008;83(10 suppl):S89–S92
40. Kennedy TJ, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: Conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22:1080–1085
41. Eva KW, Regehr G. Knowing when to look it up: A new conception of self-assessment ability. Acad Med. 2007;82(10 suppl):S81–S84
42. Sargeant J, Armson H, Chesluk B, et al. The processes and dimensions of informed self-assessment: A conceptual model. Acad Med. 2010;85:1212–1220
43. Sklar DP, Lee R. Commentary: What if high-quality care drove medical education? A multiattribute approach. Acad Med. 2010;85:1401–1404
44. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001 Washington, DC National Academies Press
45. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302:1277–1283
46. Murray CJ, Frenk J. Health metrics and evaluation: Strengthening the science. Lancet. 2008;371:1191–1199
47. Dudek NL, Marks MB, Regehr G. Failure to fail: The perspectives of clinical supervisors. Acad Med. 2005;80(10 suppl):S84–S87
48. Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: An observational study. Ann Intern Med. 2013;158:573–579
49. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32:638–645
50. Gofton WT, Dudek NL, Wood TJ, Balaa F, Hamstra SJ. The Ottawa Surgical Competency Operating Room Evaluation (O-SCORE): A tool to assess surgical competence. Acad Med. 2012;87:1401–1407
51. Crossley J, Jolly B. Making sense of work-based assessment: Ask the right questions, in the right way, about the right things, of the right people. Med Educ. 2012;46:28–37
52. Alexander EK, Osman NY, Walling JL, Mitchell VG. Variation and imprecision of clerkship grading in U.S. medical schools. Acad Med. 2012;87:1070–1076
53. Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: Translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83:761–767
54. Van Der Vleuten CP. The assessment of professional competence: Developments, research and practical implications. Adv Health Sci Educ Theory Pract. 1996;1:41–67
55. Chandratilake MN, Davis MH, Ponnamperuma G. Evaluating and designing assessments for medical education: The utility formula. Internet J Med Educ. 2010;1(1) Accessed January 23, 2014
56. Norcini J, Anderson B, Bollela V, et al. Criteria for good assessment: Consensus statement and recommendations from the Ottawa 2010 conference. Med Teach. 2011;33:206–214
57. Shepard L. The role of assessment in a learning culture. Educ Res. 2000;29:4–14
58. ten Cate O, Snell L, Carraccio C. Medical competence: The interplay between individual ability and the health care environment. Med Teach. 2010;32:669–675
59. Hodges BD. A tea-steeping or i-Doc model for medical education? Acad Med. 2010;85(9 suppl):S34–S44
60. Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85:1408–1417
61. U.S. Office of Compliance. . Policy DC-323. Medicare’s primary care exception. Accessed January 14, 2014
62. Green ML, Aagaard EM, Caverzagie KJ, et al. Charting the road to competence: Developmental milestones for internal medicine residency training. J Grad Med Educ. 2009;1:5–20
63. Dijksterhuis MG, Voorhuis M, Teunissen PW, et al. Assessment of competence and progressive independence in postgraduate clinical training. Med Educ. 2009;43:1156–1165
64. Kennedy TJ. Towards a tighter link between supervision and trainee ability. Med Educ. 2009;43:1126–1128
65. Lurie SJ. History and practice of competency-based assessment. Med Educ. 2012;46:49–57
66. Lypson ML, Frohna JG, Gruppen LD, Woolliscroft JO. Assessing residents’ competencies at baseline: Identifying the gaps. Acad Med. 2004;79:564–570
67. Sachdeva AK, Loiacono LA, Amiel GE, Blair PG, Friedman M, Roslyn JJ. Variability in the clinical skills of residents entering training programs in surgery. Surgery. 1995;118:300–308
68. Bernabeo EC, Holtman MC, Ginsburg S, Rosenbaum JR, Holmboe ES. Lost in transition: The experience and impact of frequent changes in the inpatient learning environment. Acad Med. 2011;86:591–598
69. Moulton C, Epstein RM. Self-monitoring in surgical practice: Slowing down when you should. Adv Med Educ. 2011;2:169–182
70. Lyles JS, Dwamena FC, Lein C, Smith RC. Evidence-based patient-centered interviewing. J Clin Outcomes Manage. 2001;8:28–34
71. Ptacek JT, Eberhardt TL. Breaking bad news. A review of the literature. JAMA. 1996;276:496–502
72. Searight R. Realistic approaches to counseling in the office setting. Am Fam Physician. 2009;79:277–284
73. McGee S Evidence-Based Physical Diagnosis. 2007 St. Louis, Mo Saunders Elsevier
74. Makoul G, Curry RH, Tang PC. The use of electronic medical records: Communication patterns in outpatient encounters. J Am Med Inform Assoc. 2001;8:610–615
75. Elsawy B, Higgins KE. The geriatric assessment. Am Fam Physician. 2011;83:48–56
76. Quinn TJ, McArthur K, Ellis G, Stott DJ. Functional assessment in older people. BMJ. 2011;343:d4681
77. Haan CK, Edwards FH, Poole B, Godley M, Genuardi FJ, Zenni EA. A model to begin to use clinical outcomes in medical education. Acad Med. 2008;83:574–580
© 2014 by the Association of American Medical Colleges