What is Miller’s Pyramid of Competence? Why it is Extended in 2020?

What questions will be answered in this article?

First, for those who are not familiar with it, what is the Miller Pyramid?

Why is this pyramid important for medical education?

Second, why did we need to extend it? Where does it fall short?

Third, how is the extended version? What is the new structure of the pyramid?

Flamingo is ready to answer all of them.

During the medical education journey, medical students seek to reach a level that is called as “competent”. How do we know that they are competent to become a doctor?

Sure, by assessment.

Miller Pyramid maybe the most useful tool to classify assessment levels in medical education universe. It consists of four levels: Knows, knows how, shows how, does.

While “knows” means that the student got the basic facts, “knows how” means that the student can organize these facts and apply knowledge in her mind. If you ask “what is the name of this artery”, it shows you the “knows” level. But if you provide a case for the student and ask “what is the best possible artery that would be injured in this situation?”, you assess “knows how” level. Don’t forget that “knows” and “knows how” levels are just about cognitive side, there is no behavioral aspect. So, we can use written assessment tools such as multiple choice questions and essays to assess these two levels.

Last two levels sit in the behavioral domain. “Shows how” means that the student can perform the tasks in a controlled environment, for instance in a simulation lab with standardized patients. Objective Structured Clinical Exam (OSCE) is a great tool for “shows how” level.

“Does” level is located at the top and it means that the student can perform in real clinical environment. It requires workplace-based assessment. We can assess students by using direct observations and getting feedback from their peers and the people they work with, such as nurses.

The pyramid is great! If the students reach the “does” level, it means that they have done what we want from them. So, can we give them license since they can perform when we were observing? Is it guaranteed that they can perform well when they start to work actively in a different place and situation that they would not be under supervision?

Actually we don’t know but we trust them on that. We assume they can. So we talk about somewhere that is beyond the observation. We should be sure that they can perform well even if they are not under supervision. During their medical education journey, if we gradually decrease the level of observation and at the end of the story they can perform well with zero supervision, it’s a solid sign that shows they are competent. This sign is for the entrustment of professional activities.

In every graduation, in every license that we give, accept or not, trusting students for the future performance is exactly what we do. This is where Miller Pyramid falls short. It needs another level that is where we trust the students. Observing them when they perform well is not enough. All we need is something beyond it. For instance, when the resident handles the responsibilities of an inpatient clinic during that you sleep uninterruptedly without worrying about your clinic, yes, you can trust your resident for the future performance. The resident is now at the top of the pyramid.

The source of the information I presented is the article by Olle ten Cate. You can find it at the description section of the video.

See you and adios para amigos.

And also, don’t forget these flamingos.