Introduction

Although this chapter is mainly concerned with the range of work-based assessments (WBAs) that trainees must engage with, it is important to recognise that assessments largely occur after learning and learning is structured by curriculum models. In Europe there are a number of curriculum models that have been designed to develop appropriate levels of competence and attitude in a specialism. The European Union of Medical Specialists (UEMS) coordinates the standards set within each member country for their postgraduate medical training .

Initially, trainees may be more familiar with the assessment requirements relating to their cognitive knowledge as a practitioner of their speciality, and the traditional methods, such as Multiple Choice Questionnaire (MCQ) examinations and viva voce (live, question-and-answer discussions). However, the role of WBA has recently been widely introduced at the postgraduate level, as a more valid method of assessing the application of this knowledge in a clinical context. This approach demands a professional attitude from both assessors and trainees in order to achieve acceptable levels of reliability.

Standards for postgraduate medical education in the UK have been governed by the General Medical Council (GMC). The GMC approves curricula and assessment systems developed by the royal colleges and issues doctors completing these with a Certificate of Completion of Training, thereby allowing them to practise as consultants in their chosen field as part of the Modernising Medical Careers programme. In the UK the GMC has proposed a tripartite model for undergraduate medical education :

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  the doctor as a scholar and a scientist,

  
  
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  the doctor as a practitioner and

  
  
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  the doctor as a professional.

For qualified doctors the GMC have proposed the following framework in ‘Good Medical Practice’ :

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  good clinical care,

  
  
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  maintaining good medical practice,

  
  
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  teaching and training, appraising and assessing,

  
  
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  relationships with patients,

  
  
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  working with colleagues,

  
  
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  probity and

  
  
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  health.

Increasingly, the model of the curriculum itself is being expanded and specifying the range of roles required of a professional. One widely adopted framework, Canmeds , ( Fig. 1 ), a framework launched in 2005 by the Royal College of Physicians in Canada, includes the following key roles: scholar, professional, communicator, collaborator, manager and health advocate. The website includes a repository for accounts of good practice in each of these roles, including assessment. This model was adopted by the UEMS Section of Rheumatology/European Board of Rheumatology in their European Rheumatology Curriculum Framework published in 2008 and endorsed by the vast majority of European countries.

The Canmeds curriculum framework.

With respect to rheumatology, Chapter 6 of the UEMS framework has a specific section concerned with the training of rheumatologists and the UEMS document on the ‘Core Curriculum for Specialist Training’ lists the skills and competencies shown in the box ( Fig. 2 ).

Core UEMS curriculum for rheumatology training.

All of these curriculum models should have an internal coherence so that outcomes and objectives are acquired via appropriate learning opportunities and experiences and that learning is measured and assessed via relevant assessment methods. This internal coherence is termed ‘curriculum alignment’, which should be maintained by regular curriculum evaluation and audit . A detailed analysis and critique of the structure and organisation of medical curricula at the undergraduate and postgraduate levels can be found in Fish and Coles .

From novice to expert: the development of clinical skills

Much of the list for rheumatologists, shown in the box, consists of skills that are acquired in postgraduate medical training whilst learning ‘on the job’, also termed ‘experiential learning’. This also requires that learners are assessed in the same context through various types of WBAs. This is an example of the long tradition of apprenticeship models of learning. The Oxford English Dictionary defines an apprentice as: “A learner of a craft, bound to serve, and entitled to instruction from, his or her employer for a specified period. Also a beginner or novice.” Medicine has long used the method of initiating new members to a speciality through keeping the trainees close to the master-practitioner. This draws on the powerful socialisation forces of the hidden curriculum, which is best transmitted to humans through mimicking our role models . It can also be understood as an example of how an outsider is inducted into a ‘Community of Practice’ as described by Lave and Wenger . A trainee joins a ‘Firm’ and bonds with colleagues, learning their ways as they acquire the necessary experience to move from novice to expert. In acquiring a skill by means of instruction and experience, Dreyfus argues that:

“The student normally passes through five developmental stages which we designate novice, competence, proficiency, expertise and mastery.”

Miller’s Triangle has also been applied to learning medicine to show how learners progress from basic understanding (Knows How) to be able to apply this learning appropriately in context (Shows How). The following illustration synthesises both these ideas ( Fig. 3 ).

This diagram relates the Novice – Expert taxonomy to Miller’s Know-that; Know-How Triangle to create a useful framework to delineate progress.

Research shows that to attain mastery, a consistent amount of highly focussed practice is usually required, often quoted at a minimum of 10,000 h .

From novice to expert: the development of clinical skills

Much of the list for rheumatologists, shown in the box, consists of skills that are acquired in postgraduate medical training whilst learning ‘on the job’, also termed ‘experiential learning’. This also requires that learners are assessed in the same context through various types of WBAs. This is an example of the long tradition of apprenticeship models of learning. The Oxford English Dictionary defines an apprentice as: “A learner of a craft, bound to serve, and entitled to instruction from, his or her employer for a specified period. Also a beginner or novice.” Medicine has long used the method of initiating new members to a speciality through keeping the trainees close to the master-practitioner. This draws on the powerful socialisation forces of the hidden curriculum, which is best transmitted to humans through mimicking our role models . It can also be understood as an example of how an outsider is inducted into a ‘Community of Practice’ as described by Lave and Wenger . A trainee joins a ‘Firm’ and bonds with colleagues, learning their ways as they acquire the necessary experience to move from novice to expert. In acquiring a skill by means of instruction and experience, Dreyfus argues that:

“The student normally passes through five developmental stages which we designate novice, competence, proficiency, expertise and mastery.”

Miller’s Triangle has also been applied to learning medicine to show how learners progress from basic understanding (Knows How) to be able to apply this learning appropriately in context (Shows How). The following illustration synthesises both these ideas ( Fig. 3 ).

This diagram relates the Novice – Expert taxonomy to Miller’s Know-that; Know-How Triangle to create a useful framework to delineate progress.

Research shows that to attain mastery, a consistent amount of highly focussed practice is usually required, often quoted at a minimum of 10,000 h .

Experiential learning and the Kolb cycle

The work of David Kolb and the ‘Kolb Cycle’ he developed is an extremely useful framework for understanding how individuals learn, how they should reflect and how they should approach assessments in the apprenticeship-based ‘Experiential Learning’ environments described above . Although in principle we all learn from experience, ‘experiential’ learning is the term we technically use for informal learning that occurs, usually in workplace environments such as those typically occupied by clinicians, nurses and other health-care professions. The learning that occurs while individuals are ‘on the job’ in clinics, operating theatres, wards and other clinical environments when there is no formal teaching taking place is therefore referred to as ‘experiential learning’. The ‘Kolb cycle’ differentiates this learning process into four main areas: concrete experience, reflective observation, abstract conceptualisation and active experimentation. One way of interpreting these areas is that they are steps on a cyclical process that individuals pass through as they engage in a learning process. Thus if an individual has a ‘concrete experience’, this can be followed by ‘reflective observation’ possibly leading to ‘abstract conceptualisation’ and then ‘active experimentation’. This process can occur over different time scales from minutes to hours and even days. In summary the cycle begins with ‘raw’ experience and is followed by reflections on this experience, which leads to knowledge and understanding stored in the cognitive data banks followed by possible activity. The right-hand side of the cycle can be summarised by the question “What does it mean?”, whereas the left-hand side can be summarised by the question “what shall I do?”

However, Kolb emphasised that the cyclical approach is not the only interpretation; these modes are perspectives that are available to individuals simultaneously. They can choose to concentrate on the external world of concrete experience or shift their attention to the inner world of abstract conceptualisation. Similarly individuals can move directly from reflection to action.

From an educational perspective, Kolb’s framework can be used by an individual learner or by an individual who has a supervisory or training responsibility for individuals. Although these modes are seen as natural aspects of human cognition that will occur without intervention, importantly there are ways to optimise their function. For example, ensuring that individuals are exposed to the ‘right’ experience is clearly crucial but one of the key areas that can be manipulated and enhanced is that of ‘reflective observation’ or more simply ‘reflection’. Reflection can be encouraged by the deliberate intervention of a more experienced colleague, trainer or supervisor who can, for example, debrief an individual after a specific experience or who can provide feedback after observing an individual perform a task. Encouraging an individual to engage in a conversation about their experience can promote analysis, synthesis and encourage clinical reasoning and problem solving leading to ‘deep’ learning. If it occurs after one of the assessments described below, it can also be seen as ‘formative’ assessment as previously discussed.

Portfolios, and now electronic portfolios, have been widely used for assessment purposes: at a basic level to accumulate logs of learning experiences, at a deeper level, through incorporating all stages in Kolb’s learning cycle, to demonstrate deep learning through giving an account of the reflection and the learning which has accumulated as a result of having those experiences . Portfolios can sometimes be perceived as onerous and irrelevant by learners, although more experienced learners come to value this method of cataloguing and systematically considering their achievements, particularly when they see the relevance to career-long professional updating, revalidation and practice. An outline of how portfolios can be used in medical education is provided by Pitts .

Reflective practice

The process of reflection thus has a crucial role in turning experience into learning. It cannot be emphasised enough that deliberate reflection on experience by an individual or reflection enhanced by interacting with another optimises learning. This role of reflection has been seen by a number of authors as one of the characteristics of professionalism and the professional attitude. Donald Schőn, for example, sees professionals as ‘reflective practitioner’ individuals who constantly engage in deliberate reflection before, during and after experience as a way of becoming the best possible practitioner of their particular skill set .

In the context of the present chapter, this leads us to advocate the development of the professional reflective-practitioner attitude as the best way of approaching the range of WBAs that trainees need to engage in.

The professional attitude towards assessment

Approaching assessments professionally means acknowledging that assessments serve a variety of important functions. They can serve a developmental function providing feedback on learning, identifying strengths and weaknesses and areas for improvement as well as acting as a motivating stimulus for deeper learning. They can also act as judgements, passing, failing and grading learners according to criteria set up to maintain professional standards and to reassure the public that only competent doctors are allowed to practice. Finally, assessments provide important information to teachers, trainers and curriculum organisers who need to know how well their teaching and learning frameworks are working.

The professional approach towards assessment is to acknowledge its importance and necessity in developing learners and maintaining standards as well as seeing it as valuable source of evidence for reflection on experiential learning.

A useful guide to the development of professionalism and the professional attitude in medical education can be found in Cruess et al. .

Assessment: formative and summative assessment

Clearly if learning has taken place in experiential learning environments, methods must be used to measure it in order to provide feedback to learners on their progress or to ascertain if they have achieved certain set standards designated as passing or failing. When assessment is associated with the giving of a grade, or a judgement with respect to the criteria in an assessment system, and the result is used to pass or fail a learner, we term it ‘summative assessment’. It provides a summation of what has been demonstrated after a period of learning. Inevitably learners tend to associate summative assessments with anxiety, as their career does depend on their successful completion. This often limits the amount that can be learnt through a summative assessment and the amount of feedback that an individual can benefit from. Often, the grade and the implications overshadow all other aspects.

In formative assessment, learners receive information or feedback about their performance in order to maximise their learning. It is, of course, vital for the success of the learning process. Formative assessment strives to provide information about a learner’s performance, even providing a judgement against a framework or a grade, but with the emphasis on maximising the learning. Formative assessments can be undertaken more frequently than summative assessments and can form part of a parcel of information, which the learner receives, comprising their own experience, feedback from patients, nurses and colleagues and even an indication of what grade they might receive if the process was summative.

As discussed earlier, in association with the concept of reflective practice, the most valuable aspect of feedback is the opportunity to discuss one’s performance with an expert. They can ensure that a learner gains insight into the level of their current performance indicating where that relates to the standards expected of them. They can provide specific, realistic suggestions as to how they may improve their performance. It has to be said that trainers should be trained in giving feedback using appropriate methods. Nevertheless, both learners and trainers may have an understandable tendency to attempt to avoid or reject whatever they might consider to be negative or critical. When combined with the stress of undertaking an assessment, when emotional responses might be particularly sensitive, it is not surprising that feedback is frequently considered to be less than optimal. Although feedback might often be associated with unpleasant and difficult conversations discussing failure, by both assessors and the assessed, it should be emphasised that the professional attitude is to engage fully in formative assessment and the feedback process and to reflect on how improvements can be made.