When enough is enough: a conceptual basis for fair and defensible practice performance assessment.

INTRODUCTION: An essential element of practice performance assessment involves combining the results of various procedures in order to see the whole picture. This must be derived from both objective and subjective assessment, as well as a combination of quantitative and qualitative assessment procedures. Because of the severe consequences an assessment of practice performance may have, it is essential that the procedure is both defensible to the stakeholders and fair in that it distinguishes well between good performers and underperformers. LESSONS FROM COMPETENCE ASSESSMENT: Large samples of behaviour are always necessary because of the domain specificity of competence and performance. The test content is considerably more important in determining which competency is being measured than the test format, and it is important to recognise that the process of problem-solving process is more idiosyncratic than its outcome. It is advisable to add some structure to the assessment but to refrain from over-structuring, as this tends to trivialise the measurement. IMPLICATIONS FOR PRACTICE PERFORMANCE ASSESSMENT: A practice performance assessment should use multiple instruments. The reproducibility of subjective parts should not be increased by over-structuring, but by sampling through sources of bias. As many sources of bias may exist, sampling through all of them may not prove feasible. Therefore, a more project-orientated approach is suggested using a range of instruments. At various timepoints during any assessment with a particular instrument, questions should be raised as to whether the sampling is sufficient with respect to the quantity and quality of the observations, and whether the totality of assessments across instruments is sufficient to see 'the whole picture'. This policy is embedded within a larger organisational and health care context.

Linking assessment to learning: a new route to quality assurance in medical practice.

BACKGROUND: If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a 'journey' across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues. OBJECTIVES: In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action. METHOD: To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. CONCLUSIONS: We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments.

A curriculum for SHO training--what is it and why has it changed?

The Royal Colleges of Physicians have revised the core curriculum for SHOs in medicine and the medical specialties to make it objective based. The objectives, knowledge, skills and attitudes for 'core skills' use ward based and outpatient clinical scenarios in specialty areas. There are also important sections on 'generic skills' including communication skills, team-working skills etc., cross-specialty areas, training in practical procedures and selection of investigations. Only in up to 41% of posts do SHOs in medicine get regular appraisal. A new appraisal replacing the personal training record has been designed to help SHOs reflect on their experience and identify gaps in their training using the revised curriculum. The new edition of the core curriculum should also allow the RCPs to set standards on the assessment of competence of SHOs to inform the postgraduate deans' SHO RITA process.