Context Current assessment formats for physicians and trainees reliably test
core knowledge and basic skills. However, they may underemphasize some important
domains of professional medical practice, including interpersonal skills,
lifelong learning, professionalism, and integration of core knowledge into
Objectives To propose a definition of professional competence, to review current
means for assessing it, and to suggest new approaches to assessment.
Data Sources We searched the MEDLINE database from 1966 to 2001 and reference lists
of relevant articles for English-language studies of reliability or validity
of measures of competence of physicians, medical students, and residents.
Study Selection We excluded articles of a purely descriptive nature, duplicate reports,
reviews, and opinions and position statements, which yielded 195 relevant
Data Extraction Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion
were broad, given the heterogeneity of interventions, complexity of outcome
measures, and paucity of randomized or longitudinal study designs.
Data Synthesis We generated an inclusive definition of competence: the habitual and
judicious use of communication, knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice for the benefit of the
individual and the community being served. Aside from protecting the public
and limiting access to advanced training, assessments should foster habits
of learning and self-reflection and drive institutional change. Subjective,
multiple-choice, and standardized patient assessments, although reliable,
underemphasize important domains of professional competence: integration of
knowledge and skills, context of care, information management, teamwork, health
systems, and patient-physician relationships. Few assessments observe trainees
in real-life situations, incorporate the perspectives of peers and patients,
or use measures that predict clinical outcomes.
Conclusions In addition to assessments of basic skills, new formats that assess
clinical reasoning, expert judgment, management of ambiguity, professionalism,
time management, learning strategies, and teamwork promise a multidimensional
assessment while maintaining adequate reliability and validity. Institutional
support, reflection, and mentoring must accompany the development of assessment