Clinical Competence: Knowledge or Skill or Both?
Abstract
George Miller proposed the now well-known Miller pyramid,1 which marked a departure from an emphasis on knowledge-based assessments to an assessment of clinical performance. Miller’s pyramid views the development of clinical competence in four hierarchical stages, viz. knows, knows how, shows, and does. The knowledge component forms the base of the pyramid; the next ti er comprises understanding and applicati on of knowledge; moving on to competence and fi nally to performance. Writt en tests assess the fi rst and second levels; the third by clinical examinati ons, simulati ons, and standardized pati ents; the fourth level is assessed by direct observati on in real-life clinical settings. By placing observable behavior at the top, the Miller pyramid
seems inclined towards a behaviorist rather than a cogniti vist approach to learning.
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