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Miller’s Pyramid

Miller’s pyramid of describes the competences identified for the healthcare education specially. It is useful for mapping assessment methods (Miller 1990). Competence indicates what people can do in a contextual vacuum, under perfect conditions. This might be evident using controlled assessment methods. Performance, however, indicates how people behave in real life, on a day-to-day basis. Figure 1[1] shows five levels of Miller’s pyramid model, however Table 2 classify assessment methods for every of these levels.

Figure 1: Miller’s pyramid of competence in medical sector

Following Miller (1990), the first level of the pyramid – “Know” – can be assessed using simple knowledge tests, e.g. multiple-choice questions. The ‘Knows how’ level can be assessed using unfolding patient management problems or essay questions. Objective Structured Clinical Examinations can assess the ‘Shows how’ level. The difficulty has always been assessing the ‘Does’ level, which in professional practice refers to performance in context (Miller 1990)

Table 2: Simple Model of Competence of Miller adapted for medical sector (Competence versus performance)



Assessment methods

Level 5: Does and teach

Performance mastered

Level 4: Does (applies)

in professional practice: performance in context (independent practise)

observation of performance

Level 3: Shows how

Performs under supervisions and assessment

controlled assessment methods: Objective structured clinical Examinations

Level 2: Knows how

Involvement in clinical cases and demonstration of skills (competences)

controlled assessment methods: unfolding patient management problems or essay questions

Level 1: Know

Gaining knowledge through exposure to clinical cases

controlled assessment methods: assess using simple knowledge tests, e.g. multiple-choice questions

This model concentrate on two main sectors in learning process such as Cognition (knows and knows how) and Performance (shows how, does) and can be imbedded into another conceptual frameworks to give a full picture of the learning process using simulation based training and simulation environment.