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Objectives: This study explores the optimal focus for negotiation skills development training by investigating how often medical residents negotiate in practice, and how they perceive the effectiveness of their negotiation capabilities., Methods: An exploratory study was performed using a questionnaire regarding the medical residents' working environment, negotiation frequency, knowledge and skills using a 5-point Likert scale, multiple choice questions and open questions. Exploratory factor analysis with principal component analysis, varimax rotation, reliability analysis, and content analysis were used to reduce the number of variables. Descriptive and interferential statistics and multiple regression analysis were used to analyze the data., Results: We analyzed the responses of 60 medical residents. The findings showed that the perceived development of their negotiation knowledge (M=3.06, SD=0.83) was less than their negotiation skills (M=3.69, SD=0.47). Their attitude during negotiations, especially females, differed substantially in the interactions with nurses than with their supervisors. Medical residents with more working experience, better negotiation skills or who worked in hierarchical environments negotiated more frequently with their supervisors. Medical residents with better collaboration skills and negotiation knowledge demonstrated better negotiation skills., Conclusions: This study underlines medical residents' need for negotiation training. In addition to the basic negotiation knowledge and skills, training programs in negotiation should focus on the medical residents' awareness of their attitudes during negotiations, combining the assertiveness shown in interactions with supervisors with the empathy and emotional engagement present in interactions with nurses.  Furthermore, attention should be paid to the influence of the environmental hierarchy on negotiation skill development.

Background: The current shift towards competency-based residency training has increased the need for objective assessment of skills. In this study, we developed and validated an assessment tool that measures technical and non-technical competency in transurethral resection of bladder tumour (TURBT)., Methods: The 'Test Objective Competency' (TOCO)-TURBT tool was designed by means of cognitive task analysis (CTA), which included expert consensus. The tool consists of 51 items, divided into 3 phases: preparatory (n = 15), procedural (n = 21), and completion (n = 15). For validation of the TOCO-TURBT tool, 2 TURBT procedures were performed and videotaped by 25 urologists and 51 residents in a simulated setting. The participants' degree of competence was assessed by a panel of eight independent expert urologists using the TOCO-TURBT tool. Each procedure was assessed by two raters. Feasibility, acceptability and content validity were evaluated by means of a quantitative cross-sectional survey. Regression analyses were performed to assess the strength of the relation between experience and test scores (construct validity). Reliability was analysed by generalizability theory., Results: The majority of assessors and urologists indicated the TOCO-TURBT tool to be a valid assessment of competency and would support the implementation of the TOCO-TURBT assessment as a certification method for residents. Construct validity was clearly established for all outcome measures of the procedural phase (all r > 0.5, p < 0.01). Generalizability-theory analysis showed high reliability (coefficient Phi ≥ 0.8) when using the format of two assessors and two cases., Conclusions: This study provides first evidence that the TOCO-TURBT tool is a feasible, valid and reliable assessment tool for measuring competency in TURBT. The tool has the potential to be used for future certification of competencies for residents and urologists. The methodology of CTA might be valuable in the development of assessment tools in other areas of clinical practice.

Background: Items must be relevant to ensure item quality and test validity. Since "item relevance" has not been operationalized yet, we developed a rubric to define it. This study explores the influence of this rubric on the assessment of item relevance and on inter-rater agreement., Methods: Members of the item review committee (RC) and students, teachers, and alumni (STA) reassessed the relevance of 50 previously used progress test (PT) items and decided about their inclusion using a 5-criteria rubric. Data were analyzed at item level using paired samples t-tests, Intraclass Correlation Coefficients (ICC), and linear regression analysis, and at rater level in a generalizability analysis per group., Results: The proportion of items that the RC judged relevant enough to be included decreased substantially from 1.00 to 0.72 (p < 0.001). Agreement between the RC and STA was high, with an ICC of >0.7 across items. The relation between inclusion and relevance was strong (correlation = 0.89, p < 0.001), and did not differ between RC and STA. To achieve an acceptable inter-rater reliability for relevance and inclusion, 6 members must serve on the RC., Conclusions: Use of the rubric results in a stricter evaluation of items' appropriateness for inclusion in the PT and facilitates agreement between the RC and other stakeholders. Hence, it may help increase the acceptability and validity of the PT.

Background: It remains unclear which item format would best suit the assessment of clinical reasoning: context-rich single best answer questions (crSBAs) or key-feature problems (KFPs). This study compared KFPs and crSBAs with respect to students' acceptance, their educational impact, and psychometric characteristics when used in a summative end-of-clinical-clerkship pediatric exam., Methods: Fifth-year medical students (n = 377) took a computer-based exam that included 6-9 KFPs and 9-20 crSBAs which assessed their clinical reasoning skills, in addition to an objective structured clinical exam (OSCE) that assessed their clinical skills. Each KFP consisted of a case vignette and three key features using a "long-menu" question format. We explored students' perceptions of the KFPs and crSBAs in eight focus groups and analyzed statistical data of 11 exams., Results: Compared to crSBAs, KFPs were perceived as more realistic and difficult, providing a greater stimulus for the intense study of clinical reasoning, and were generally well accepted. The statistical analysis revealed no difference in difficulty, but KFPs resulted more reliable and efficient than crSBAs. The correlation between the two formats was high, while KFPs correlated more closely with the OSCE score., Conclusions: KFPs with long-menu exams seem to bring about a positive educational effect without psychometric drawbacks.

Background: Although simulation training is increasingly used to meet modern technology and patient safety demands, its successful integration within surgical curricula is still rare. The Dutch Urological Practical Skills (D-UPS) curriculum provides modular simulation-based training of technical and non-technical basic urological skills in the local hospital setting. This study aims to assess the educational impact of implementing the D-UPS curriculum in the Netherlands and to provide focus points for improvement of the D-UPS curriculum according to the participants., Methods: Educational impact was assessed by means of qualitative individual module-specific feedback and a quantitative cross-sectional survey among residents and supervisors. Twenty out of 26 Dutch teaching hospitals participated. The survey focussed on practical aspects, the D-UPS curriculum in general, and the impact of the D-UPS curriculum on the development of technical and non-technical skills., Results: A considerable survey response of 95 % for residents and 76 % for supervisors was obtained. Modules were attended by junior and senior residents, supervised by a urologist, and peer teaching was used. Ninety percent of supervisors versus 67 % of residents judged the D-UPS curriculum as an important addition to current residency training (p = 0.007). Participants' aggregated general judgement of the modules showed a substantial percentage favorable score (M ± SE: 57 ± 4 %). The impact of training on, e.g., knowledge of materials/equipment and ability to anticipate on complications was high, especially for junior residents (77 ± 5 and 71 ± 7 %, respectively). Focus points for improvement of the D-UPS curriculum according to the participants include adaptation of the training level to residents' level of experience and focus on logistics., Conclusion: The simulation-based D-UPS curriculum has a high educational impact. Residents and supervisors consider the curriculum to be an important addition to current residency training. Focus points for improvement of the D-UPS curriculum according to the participants include increased attention to logistics and integration of a spiral learning approach.

Background: Portfolios are used as tools to coach and assess students in the workplace. This study sought to evaluate the content validity of portfolios as reflected in their capacity to adequately assess achieved competences of medical students during clerkships., Methods: We reviewed 120 workplace portfolios at three medical universities (Belgium and the Netherlands). To validate their content, we developed a Validity Inventory for Portfolio Assessment (VIPA) based on the CanMEDS roles. Two raters evaluated each portfolio and indicated for each VIPA item whether the portfolio provided sufficient information to enable satisfactory assessment of the item. We ran a descriptive analysis on the validation data and computed Cohen's Kappa to investigate interrater agreement., Results: The portfolios adequately covered the items pertaining to the communicator (90%) and professional (87%) roles. Coverage of the medical expert, collaborator, scholar and manager roles ranged between 75% and 85%. The health advocate role, covering 59%, was clearly less well represented. This role also exhibited little interrater agreement (Kappa < 0.4)., Conclusions: This study lends further credence to the evidence that portfolios can indeed adequately assess the different CanMEDS roles during clerkships, the health advocate role, which was less well represented in the portfolio content, excepted.

Background: Although preparation for educational activities is considered beneficial for student learning, many students do not perform preparatory assignments. This phenomenon has received little attention in the literature although it might provide medical educators with the opportunity to enhance student learning. Therefore, we explored why students prepare or not prepare., Methods: An explorative mixed methods study was performed. In a qualitative study, 24 short group interviews with medical undergraduate students (n=209) were conducted on why they prepared for skills training sessions. In a subsequent quantitative study the resulting themes were used to construct a questionnaire. The questionnaire was presented to all undergraduate medical students at Maastricht University and 847 students completed it. Scales were constructed by a combination of exploratory factor analysis, reliability analysis, and content analysis. Between-class differences in the scale scores were investigated using ANOVA., Results: The qualitative study showed that students' opinions on preparation are influenced by both personal factors, categorized as 'personal learning style', 'attitudes and beliefs', and 'planning and organization', as well as external factors, including 'preparatory advice', 'pressure, consequence, and checking of preparation', 'teacher-related motivations', and 'contents and schedule of the training sessions'. The quantitative study showed that 'the objective structured clinical examination' and 'facilitation of both understanding and memorizing the learning material', were the two most motivating items. The two most demotivating aspects were 'other students saying that preparation was not useful' and 'indistinct preparatory advices'. Factor analyses yielded three scales: 'urge to learn', 'expected difficulties', and 'lack of motivation'. Between group differences were found between the three classes on the first two scales., Conclusions: Students make an active and complex choice whether to prepare or not, based on multiple factors. Practical implications for educational practice are discussed.

Aim: There is growing pressure from the government and the public to define proficiency standards for surgical skills. Aim of this study was to estimate the reliability of the Program for Laparoscopic Urological Skills (PLUS) assessment and to set a certification standard for second-year urological residents., Methods: Fifty participants were assessed on performance time and performance quality to investigate the reliability of the PLUS assessment. Generalisability coefficient of 0.8, on a scale of 0 to 1.0, was considered to indicate good reliability for assessment purposes. Pass/fail standards were based on laparoscopic experience: Novices, intermediates, and experts (>100 procedures). The pass/fail standards were investigated for the PLUS performances of 33 second-year urological residents., Results: Fifteen novices, twenty-three intermediates and twelve experts were included. An inter-trial reliability of >0.80 was reached with two trials for each task. Inter-rater reliability of the quality measurements was 0.79 for two judges. Pass/fail scores were determined for the novice/intermediate boundary and the intermediate/expert boundary. Pass rates for second-year residents were 63.64% and 9.09%, respectively., Conclusion: The PLUS assessment is reliable for setting a certification standard for second-year urological residents that serves as a starting point for residents to proceed to the next level of laparoscopic competency.

Background: Visual expertise relies on perceptive as well as cognitive processes. At present, knowledge of these processes when diagnosing clinical cases mainly stems from studies with still pictures. In contrast, patient video cases constitute a dynamic diagnostic challenge that may simulate seeing and diagnosing a patient in person., Aims: This study investigates visual attention and the concomitant cognitive processes of clinicians diagnosing authentic paediatric video cases., Methods: A total of 43 clinicians with varying levels of expertise took part in this cross-sectional study. They diagnosed four brief video recordings of children: two with seizures and two with disorders imitating seizures. We used eye tracking to investigate time looking at relevant areas in the video cases and a concurrent think-aloud procedure to explore the associated clinical reasoning processes., Results: More experienced clinicians were more accurate in visual diagnosis and spent more of their time looking at relevant areas. At the same time, they explored data less, yet they built and evaluated more diagnostic hypotheses., Conclusions: Clinicians of varying expertise analyse patient video cases differently. Clinical teachers should take these differences into account when optimising educational formats with patient video cases., (Copyright © 2011 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.)

Objective: • To establish the effect of distraction on the performance of cystoscopy and basic endourological tasks by using a virtual reality (VR) simulator., Subjects and Methods: • A total of 86 third-year medical students from Maastricht University, who had no previous experience in performing the tasks on a VR simulator, were randomly assigned to an intervention or control group. • All participants performed three endourological tasks on the VR simulator. Participants in the intervention group were distracted 1 min into the third task. The distraction consisted of being asked to answer questions about a medical case that had been presented to all the participants before the hands-on session. After two adequate verbal responses the conversation was terminated. • Number of traumata, number of missed lesions in the bladder and time to completion were measured by the VR simulator., Results: • Number of traumata and missed lesions, as well as time to completion were significantly higher in the intervention than in the control group with effect sizes (using Cohen's categorization) of 0.48, 0.41 and 0.50 respectively. • Nevertheless, only 9.5% of the participants in the intervention group reported feeling burdened by the distraction., Conclusions: • Distraction during the performance of endourological skills results in significantly poorer performance by medical students on all the variables measured in a controlled learning environment. • Most students do not realize they are affected by distraction. • Further research is needed to determine the impact of distraction on more experienced participants and on patient safety., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Introduction: Models for training urological procedures without burdening patients are available at varying costs. We examined the value of training on a low-fidelity model in addition to training on a high-fidelity simulator in a cystoscopy training program., Methods: Thirty-two medical students were randomized to an intervention and a control group. The former started by performing cystoscopy on a low-cost, low-fidelity, glass globe model before moving on to training on the URO Mentor (UM), a computerized simulator. The control group took part in the same UM training program but not in the low-fidelity training. Performance on UM was assessed by a global rating score, percentage of correctly inspected areas of the bladder (% inspected areas), time, and number of traumas caused., Results: The intervention group had generally higher scores. Its global rating score on task 1 was significantly higher than that of the control group (Mann-Whitney U test, P = 0.046, effect size 0.6) and the group also scored higher, albeit not significantly, on time and % inspected areas. All students said they valued training with UM, but the appreciation of the intervention group was stronger (mean 8.9 vs. 8.1 on a scale from 1 to 10, P = 0.017, effect size 1.8)., Conclusion: A low-fidelity glass globe model seemed to be an inexpensive educational tool to practice the first steps of cystoscopy. It may reduce training time on the UM simulator. The combined use of a low- and high-fidelity training model may provide an optimal learning effect.

Objective: To assess whether real-time cysto-urethroscopy (CUS) performance improves by simulator-based training (criterion or predictive validity), addressing the research question 'Does practical skills training on the URO Mentor (UM, Simbionix USA Corp., Cleveland, OH, USA) virtual-reality simulator improve the performance of flexible CUS in patients'., Subjects and Methods: Participants (71 interns from Catharina Hospital Eindhoven, CHE, and 29 from University Medical Centre Groningen, UMCG) were randomized to carry out CUS in a patient after training on the UM (UM-trained, 50) or without training on UM (control, 50). The assessment of real-time performance consisted of scoring on a Global Rating Scale (GRS) by supervisors unaware of training status. Data were analysed using stepwise multiple linear regression. The effect size (ES) indication for correlations was used to interpret the magnitude of a standard regression coefficient (beta); an ES of 0.10, 0.30 and 0.50 were considered small, moderate and large, respectively. The study was approved by the Medical Review Ethics Committees of the participating hospitals., Results: Overall, the group that received training performed significantly better than the controls (P < or = 0.003, beta range 0.30-0.47). There was no effect of training for participants with a specific preference for a surgical speciality in two of five GRS scores. Participants from CHE obtained higher GRS 3 scores than those from UMCG. Significantly more UMCG trainees indicated having had stress than those from CHE (P < 0.001)., Conclusions: The results showed that interns who had trained on UM outperformed controls for a CUS procedure in a patient. Training for CUS on the UM is to be recommended for learning to respect tissue, procedural knowledge, flow of procedure and forward planning. Use of the UM to train interns with a specific interest in a surgical speciality in handling instruments, and time and motion, seems to be of limited value.

Introduction: The emphasis on the importance of professionalism in a recent CoBaTrICE-IT paper was impressive. However, insight into the elements of professionalism as perceived relevant for intensivists from the fellows' view, and how these are taught and learned, is limited., Objectives and Methods: A nationwide study was performed in 2007-2008. All ICM fellows (n = 90) were sent a questionnaire containing the following questions regarding training in professionalism (7-point Likert scale (1 = very inadequate, 7 = very adequate)): which are the elements perceived to be important in intensivists'' daily practice (38 items, cat. I)? Which methods of learning and teaching are recognised (16 items, cat. II)? Which methods of teaching and learning are considered especially useful (16 items, cat. III)? Finally, the perceived quantity and quality of formal and informal learning methods, as well as the responsible organisational body was studied. Data were analysed using SPSS 15.0., Results: Response was 75.5 % (n = 68), mean age 34 years. Regarding Elements, scores on virtually all items were high. The factor 'striving for excellence' explained half the variance. Two other aspects, 'Teamwork' and 'Dealing with ethical dilemmas', were identified. Regarding Methods, three dimensions, 'formal curriculum'', 'private and academic experiences' and 'role modelling', proved important. The factor 'formal curriculum' explained most of the variance. Regarding Usefulness the same factors, now mainly explained by the factor Private and academic experiences, emerged with variance. In both categories the items 'observations in daily practice' and 'watching television programmes like ER and House' were the highest- and lowest-scoring items (5.99 and 5.81, and 2.69 and 2.49, respectively). Mean scores regarding the quantity of formal and informal teaching were 4.06 and 4.58 (range 1.841 and 1.519). For the quality of teaching, the figures were 4.22 and 4.52 (range 1.659 and 1.560, respectively). 54 suggestions for improvement of teaching were documented. The need for some form of formal teaching of professionalism aspects as well as for feedback was most frequently mentioned (n = 19 and 16). The local training centres are considered and should remain pivotal for teaching professionalism issues (n = 17 and 28)., Conclusions: Almost all elements of professionalism were considered relevant to intensivists' daily practice. Although formal teaching methods regarding professionalism aspects are easily recognised in daily practice, learning by personal experiences and informal ways quantitatively plays a more important, and more valued role. Qualitative comments, nevertheless, stress the need for providing and receiving (solicited and unsolicited) feedback, thereby requesting expansion of formal teaching methods. The local training centres (should continue to) play a major role in teaching professionalism, although an additional role for the (inter)national intensive care organisations remains.

Objective: To assess the construct validity of the URO Mentor (Simbionix Corp., Cleveland, OH, USA) virtual reality training model for several variables of skills training in cysto-urethroscopy, addressing two research questions: (i) Does training on the URO Mentor significantly improve novices' performance in terms of time, trauma, areas inspected and Global Rating Scale (GRS) score?; (ii) is discrimination between different levels of expertise possible using the URO Mentor?, Methods: Thirty experts and 50 novices performed seven tasks on the URO Mentor during one training session. The first, fourth and seventh tasks were 'test tasks' to evaluate participants' performance. The simulator recorded procedure time and trauma; a supervisor scored which areas were inspected and gave scores on the GRS. A two-way analysis of variance with repeated-measures test was used to analyse experts' and novices' performances, with P < 0.05 considered to indicate statistical significance. Effect sizes (ES) were calculated to quantify the practical significance of the results; ES of 0.10, 0.30, and 0.50 were considered small, medium and large, respectively., Results: Novices' performances showed a significant improvement with large ES in time (linear trend of learning curve P < 0.001, ES 0.66) and mean GRS score (linear trend P < 0.001, ES 0.84, quadratic trend P = 0.018, ES 0.24). There was a medium improvement for trauma (linear trend P < 0.001, ES 0.40) and a small improvement in areas inspected (linear trend P = 0.032, ES 0.21). That the 95% confidence intervals of the measures on the first task of experts and novices did not coincide indicates that differentiation between experts and novices on the four variables measured can be achieved using the URO Mentor., Conclusions: Training on the URO Mentor appears to result in a medium to large improvement of novices' performances for time, trauma, areas inspected and GRS scores. Moreover, discrimination between different levels of expertise is possible using this simulator.

Background: A portfolio is used to mentor and assess students' clinical performance at the workplace. However, students and raters often perceive the portfolio as a time-consuming instrument., Purpose: In this study, we investigated whether assessment during medical internship by a portfolio can combine reliability and feasibility., Methods: The domain-oriented reliability of 61 double-rated portfolios was measured, using a generalisability analysis with portfolio tasks and raters as sources of variation in measuring the performance of a student., Results: We obtained reliability (Phi coefficient) of 0.87 with this internship portfolio containing 15 double-rated tasks. The generalisability analysis showed that an acceptable level of reliability (Phi = 0.80) was maintained when the amount of portfolio tasks was decreased to 13 or 9 using one and two raters, respectively., Conclusions: Our study shows that a portfolio can be a reliable method for the assessment of workplace learning. The possibility of reducing the amount of tasks or raters while maintaining a sufficient level of reliability suggests an increase in feasibility of portfolio use for both students and raters.

Context: One goal of undergraduate assessment is to test students' (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills?, Methods: Undergraduate students (n = 32) were given a questionnaire listing 182 basic clinical skills. We asked them to score the number of times they had performed each skill during their internships (a 12-month period in Year 6). We assessed the students at the end of Year 5 (before the start of their internships) and again at the start of Year 7 (undergraduate training takes 7 years in Belgium, with internships during Year 6), using a 14-station OSCE assessing basic clinical skills. Global ratings were used to score performance. The relationship between internship experience and the OSCE Year 7 score was analysed using a linear regression model, controlling for variation in OSCE scores from Year 5. A multi-level analysis was performed considering students as level-1 units and stations as level-2 units., Results: Year 7 OSCE scores (post-internships) were not affected by the number of times that students practised basic medical skills during their internships., Discussion: Scores on OSCEs do not seem to reflect clinical expertise acquired during internships. Other more integrated assessment methods may prove to be more valid for testing final undergraduate skills levels.

Objective: To test hypotheses regarding the longitudinal effects of problem-based learning (PBL) and conventional learning relating to students' appreciation of the curriculum, self-assessment of general competencies, summative assessment of clinical competence and indicators of career development., Methods: The study group included 2 complete cohorts of graduates who were admitted to the medical curriculum in 1992 (conventional curriculum, n = 175) and 1993 (PBL curriculum, n = 169) at the Faculty of Medicine, University of Groningen, the Netherlands. Data were obtained from student records, graduates' self-ratings and a literature search. Gender and secondary school grade point average (GPA) scores were included as moderator variables. Data were analysed by a stepwise multiple and logistic regression analysis., Results: Graduates of the PBL curriculum scored higher on self-rated competencies. Contrary to expectations, graduates of the PBL curriculum did not show more appreciation of their curriculum than graduates of the conventional curriculum and no differences were found on clinical competence. Graduates of the conventional curriculum needed less time to find a postgraduate training place. No differences were found for scientific activities such as reading scientific articles and publishing in peer- reviewed journals. Women performed better on clinical competence than did men. Grade point average did not affect any of the variables., Conclusions: The results suggest that PBL affects self-rated competencies. These outcomes confirm earlier findings. However, clinical competence measures did not support this finding.

Objective: To determine whether items of progress tests used for inter-curriculum comparison favour students from the medical school where the items were produced (i.e. whether the origin bias of test items is a potential confounder in comparisons between curricula)., Methods: We investigated scores of students from different schools on subtests consisting of progress test items constructed by authors from the different schools. In a cross-institutional collaboration between 3 medical schools, progress tests are jointly constructed and simultaneously administered to all students at the 3 schools. Test score data for 6 consecutive progress tests were investigated. Participants consisted of approximately 5000 undergraduate medical students from 3 medical schools. The main outcome measure was the difference between the scores on subtests of items constructed by authors from 2 of the collaborating schools (subtest difference score)., Results: The subtest difference scores showed that students obtained better results on items produced at their own schools. This effect was more pronounced in Years 2-5 of the curriculum than in Year 1, and diminished in Year 6., Conclusions: Progress test items were subject to origin bias. As a consequence, all participating schools should contribute equal numbers of test items if tests are to be used for valid and fair inter-curriculum comparisons.

Context: In-training assessment (ITA), defined as multiple assessments of performance in the setting of day-to-day practice, is an invaluable tool in assessment programmes which aim to assess professional competence in a comprehensive and valid way. Research on clinical performance ratings, however, consistently shows weaknesses concerning accuracy, reliability and validity. Attempts to improve the psychometric characteristics of ITA focusing on standardisation and objectivity of measurement thus far result in limited improvement of ITA-practices., Purpose: The aim of the paper is to demonstrate that the psychometric framework may limit more meaningful educational approaches to performance assessment, because it does not take into account key issues in the mechanics of the assessment process. Based on insights from other disciplines, we propose an approach to ITA that takes a constructivist, social-psychological perspective and integrates elements of theories of cognition, motivation and decision making. A central assumption in the proposed framework is that performance assessment is a judgment and decision making process, in which rating outcomes are influenced by interactions between individuals and the social context in which assessment occurs., Discussion: The issues raised in the article and the proposed assessment framework bring forward a number of implications for current performance assessment practice. It is argued that focusing on the context of performance assessment may be more effective in improving ITA practices than focusing strictly on raters and rating instruments. Furthermore, the constructivist approach towards assessment has important implications for assessment procedures as well as the evaluation of assessment quality. Finally, it is argued that further research into performance assessment should contribute towards a better understanding of the factors that influence rating outcomes, such as rater motivation, assessment procedures and other contextual variables.

Workplace-Based Assessment (WBA) plays a pivotal role in present-day competency-based medical curricula. Validity in WBA mainly depends on how stakeholders (e.g. clinical supervisors and learners) use the assessments-rather than on the intrinsic qualities of instruments and methods. Current research on assessment in clinical contexts seems to imply that variable behaviours during performance assessment of both assessors and learners may well reflect their respective beliefs and perspectives towards WBA. We therefore performed a Q methodological study to explore perspectives underlying stakeholders' behaviours in WBA in a postgraduate medical training program. Five different perspectives on performance assessment were extracted: Agency, Mutuality, Objectivity, Adaptivity and Accountability. These perspectives reflect both differences and similarities in stakeholder perceptions and preferences regarding the utility of WBA. In comparing and contrasting the various perspectives, we identified two key areas of disagreement, specifically 'the locus of regulation of learning' (i.e., self-regulated versus externally regulated learning) and 'the extent to which assessment should be standardised' (i.e., tailored versus standardised assessment). Differing perspectives may variously affect stakeholders' acceptance, use-and, consequently, the effectiveness-of assessment programmes. Continuous interaction between all stakeholders is essential to monitor, adapt and improve assessment practices and to stimulate the development of a shared mental model. Better understanding of underlying stakeholder perspectives could be an important step in bridging the gap between psychometric and socio-constructivist approaches in WBA. [ABSTRACT FROM AUTHOR]

Context The portfolio is becoming increasingly accepted as a valuable tool for learning and assessment. The validity of portfolio assessment, however, may suffer from bias due to irrelevant qualities, such as lay-out and writing style. We examined the possible effects of such qualities in a portfolio programme aimed at stimulating Year 1 medical students to reflect on their professional and personal development. In later curricular years, this portfolio is also used to judge clinical competence. Methods We developed an instrument, the Portfolio Analysis Scoring Inventory, to examine the impact of form and content aspects on portfolio assessment. The Inventory consists of 15 items derived from interviews with experienced mentors, the literature, and the criteria for reflective competence used in the regular portfolio assessment procedure. Forty portfolios, selected from 231 portfolios for which ratings from the regular assessment procedure were available, were rated by 2 researchers, independently, using the Inventory. Regression analysis was used to estimate the correlation between the ratings from the regular assessment and those resulting from the Inventory items. Results Inter-rater agreement ranged from 0.46 to 0.87. The strongest predictor of the variance in the regular ratings was ‘quality of reflection’ (R 0.80; R2 66%). No further items accounted for a significant proportion of variance. Irrelevant items, such as writing style and lay-out, had negligible effects. Conclusions The absence of an impact of irrelevant criteria appears to support the validity of the portfolio assessment procedure. Further studies should examine the portfolio's validity for the assessment of clinical competence. [ABSTRACT FROM AUTHOR]