TY - JOUR T1 - Moving Up the Pyramid: Assessing Performance in the Clinic JF - The Journal of Rheumatology JO - J Rheumatol SP - 1101 LP - 1103 DO - 10.3899/jrheum.090085 VL - 36 IS - 6 AU - STEPHEN AARON Y1 - 2009/06/01 UR - http://www.jrheum.org/content/36/6/1101.abstract N2 - More that 18 years ago, George Miller introduced a framework for the assessment of medical students and residents, “Miller’s Pyramid”1 (Figure 1). In the accompanying address to the Association of American Medical Colleges, he advocated the evaluation of learners for their skills and abilities in the 2 top cells of the pyramid, in the domains of action, or performance, reflecting clinical reality. Miller argued that the demonstration of competence in these higher domains strongly implies that a student has already acquired the prerequisite knowledge, or Knows, and the ability to apply that knowledge, or Knows How, that make up the base of the pyramid. Basic clinical skills (Shows How) are those that can be measured in an examination situation such as an objective structured clinical examination (OSCE). However, the professionalism and motivation required to continuously apply these in the real setting (Does) must be observed during actual patient care.Figure 1. Miller’s pyramid1. From Academic Medicine 1990;65:S63–7; with permission from Wolters Kluwer Health.The component that Miller argued is the most vital aspect of measurement, what the learner does in clinical practice, has been the most difficult to capture. Almost 2 decades later, we are still struggling with the need to develop reliable and valid methods of assessing learners in the clinical setting.In the meantime, there have been many advances in the lower echelons of the pyramid. In the domains of Know and Know How, the Medical Council of Canada2 and the National Board of Medical Examiners3 have made great strides in the art of the multiple choice examination, the Key Feature examination, and computer-based, adaptive examination. In a pair of landmark publications, Tamblyn, et al have provided good evidence of the predictive validity of these assessments … Address reprint requests to Dr. Aaron, Heritage Medical Research Center, 562-107 University Campus NW, Edmonton, AB T6G 2S2. ER -