Revisiting Miller's pyramid in medical education: the gap between traditional assessment and diagnostic reasoning

Miller's pyramid model divides the development of clinical competence into four, hierarchical processes.1 On the lowest level of the pyramid is 'knowledge', tested by written exams and traditional multiple-choice questions (MCQs).2 The next level stands for 'application of knowledge', assessed by essays, clinical problem-solving exercises and extended MCQs.2 The third tier of the pyramid represents 'clinical skills competency', assessed by standardized patient exercises, simulations and clinical exams.2 Finally, on top of the pyramid is 'clinical performance', assessed by direct observation in real clinical settings.2 The lower level processes account for the cognitive components of competence and involve classroom-based assessments, while the two higher tiers of the pyramid account for the behavioural components of clinical competence, which involve assessment in simulated and real clinical settings.3 By placing the observable behaviour at the apex of the hierarchy, Miller's pyramid implies a preference towards the behaviourist tradition, as opposed to cognitive perspectives. Due to the context dependent nature of diagnostic reasoning, it is important for learners to demonstrate their reasoning process of solving diagnostic problems in a clinical context. [...]the upper tiers of Miller's pyramid need to incorporate 'sound diagnostic reasoning' assessed first in simulated, and then in the real-world, clinical setting. Considering the importance of sound diagnostic reasoning skills for safe clinical practice, it is essential that medical graduates entering clinical practice are assessed on this skill in order to make sure they have the necessary skills to practice safely in their new role as junior doctors. [...]it is important to put in place adequate assessment methods in undergraduate medical education, which focuses on the use of diagnostic reasoning.