Three key issues for determining competence in a system of assessment.

There is widespread agreement that medical education should include multi-source, multi-method, and multi-purpose forms of assessment and thus should move towards cohesive systems of assessment. One possibility that fits comfortably with a system of assessment framework is to organize assessments around a competency based medical education model. However conceptually appealing a competency based medical education model is, discussions are sparse regarding the details of determining competence (or the pass/fail point) within each competency. In an effort to make discussions more concrete, we put forth three key issues relevant to implementation of competency-based assessment: (1) each competency is measured with multiple assessments, (2) not all assessments produce a score for a competency as a good portion of assessment in medical school is narrative, and (3) competence decisions re-occur as assessments cumulate. We agree there are a host of other issues to consider, but think the practical action-oriented issues we set forth will be helpful in putting form into what is now largely abstract discussions.