The meaningful assessment of competence is critical for the implementation of effective competency-based medical education (CBME). Timely ongoing assessments are needed along with comprehensive periodic reviews to ensure that trainees continue to progress. New approaches are needed to optimize the use of multiple assessors and assessments; to synthesize the data collected from multiple assessors and multiple types of assessments; to develop faculty competence in assessment; and to ensure that relationships between the givers and receivers of feedback are appropriate. This paper describes the core principles of assessment for learning and assessment of learning. It addresses several ways to ensure the effectiveness of assessment programs, including using the right combination of assessment methods and conducting careful assessor selection and training. It provides a reconceptualization of the role of psychometrics and articulates the importance of a group process in determining trainees' progress. In addition, it notes that, to reach its potential as a driver in trainee development, quality care, and patient safety, CBME requires effective information management and documentation as well as ongoing consideration of ways to improve the assessment system.

ECADES OF RESEARCH HAVEconfirmed that poor skills in patient communication are associated with lower levels of patient satisfaction, higher rates of complaints, an increased risk of malpractice claims, and poorer health outcomes. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Medical schools have responded by incorporating training in patient communication and clinical skills into the curriculum. However, these skills were not systematically evaluated, nor was a minimum level of proficiency required for medical licensure. 17 To address this problem, licensure reforms were undertaken in North America. 18 The Medical Council of Canada (MCC) (1993), 19 the Educational Commission for Foreign Medical Graduates (1998), 20 and most recently the United States Medical Licensing Examination (USMLE) ( 2004) 21 have all introduced a clinical skills examination (CSE)-a nationally standardized assessment of patient-physician communication, clinical history taking, and examination skills-as a requirement for licensure. All US and Canadian medical For editorial comment see p 1057.

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Doctor scores on qualifying examinations are significant predictors of quality-of-care problems based on regulatory, practice-based peer assessment.

Current techniques do not provide a reproducible, reliable, or valid basis for assessing clinical skills. The need for large-scale direct observation and standardized assessment procedures has precluded development of better techniques. A project using standardized patients presenting with common clinical problems evaluated the skills of 336 internal medicine residents at 14 New England residency programs in 1289 standardized patient and resident encounters. Results indicated that reproducible assessment of the clinical skills could be achieved in approximately 1 day of testing time using standardized patients. Resident performance improved with years of training, and senior residents and those from programs with stronger reputations performed better and were more homogeneous in ability. Low correlations between standardized-patient-based measures of clinical skills and other evaluation techniques suggested that standardized patients provided unique information. Reactions of residents and faculty to standardized-patient-based evaluations were favorable.

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Although standardized patients have been employed for formative assessment for over 40 years, their use in high-stakes medical licensure examinations has been a relatively recent phenomenon. As part of the medical licensure process in the United States and Canada, the clinical skills of medical students, medical school graduates, and residents are evaluated in a simulated clinical environment. All of the evaluations attempt to provide the public with some assurance that the person who achieves a passing score has the knowledge and/or requisite skills to provide safe and effective medical services. Although the various standardized patient-based licensure examinations differ somewhat in terms of purpose, content, and scope, they share many commonalities. More important, given the extensive research that was conducted to support these testing initiatives, combined with their success in promoting educational activities and in identifying individuals with clinical skills deficiencies, they provide a framework for validating new simulation modalities and extending simulation-based assessment into other areas.