Work-place Methods of Assessment

CanMedEd-ipedia: The CORAL Collection. Concepts as Online Resources for Accelerated Learning.


Assessment drives learning thereby ensuring that learners are prepared for the next stage of training. Assessment guides student studying and the results provide feedback. This cell is designed to give you an overview of important issues surrounding workplace-based assessment.

Learning Objectives (what you can reasonably expect to learn in the next 15 minutes):

  1. Describe the uses and potential benefits of workplace-based assessment.
  2. Given an assessment situation (mini-case) identify the weakness or weaknesses: Time, Lack of standardization, Variability in assessor judgements, Systematic bias or biases (BONUS: identify the bias).

To what extent are you now able to meet the objectives above? Please record your self-assessment. (0 is Not at all and 5 is Completely)

To what extent are you now able to meet this objective above?

To get started, please take a few moments to list your thoughts on the potential benefits and challenges of workplace-based assessment:

Now proceed to the rest of this CORAL Cell.

An Introduction to Workplace-based assessment

Workplace-based assessment represents the “Does” level of Millar’s pyramid, i.e. what learners do as part of their actual work. Learners can be assessed performing a wide variety of tasks, such as taking a history, performing a procedure, eliciting informed consent, counselling a patient, presenting a case to their supervisor, consigning findings to the chart, preparing orders, writing a referral or discharge letter, handing-over cases to colleagues, contributing to multidisciplinary rounds, .… The assessment can use different types of evidence such as direct observation of learner performance, written evidence, or evidence from discussions. It can be conducted on specific events or longitudinally aggregating multiple events. Some examples of workplace-based assessment methods are provided in the table below:

Evidence through direct observation Other sources of evidence
Single Event

Informal assessment and feedback

Clinical Evaluation Exercise

(e.g. Mini CEX, PMEX, O-SCORE, TMEX..)

Video assessment

Case presentation

Case-based discussion

Chart review

Discharge/referral letter

Critical incident

Reflective paper
Aggregate of multiple events

End of rotation form (ITER)

Multisource feedback

Chart audit

Encounter log


Potential benefits

Workplace-based assessment has high face validity, in that it represents what learners are actually doing and what they will likely do in their future practices1,2. As such, it enables the assessment of performance in its real context, with all of its complexities and challenges. It also has the potential of providing rich feedback that learners often attend to with great diligence1,2.



The imperative of patient care means that it may be difficult for assessors to take the time to observe performance, document their findings, and provide feedback.

Lack of standardisation

The assessment tasks and settings will not be standardised for all learners. Cases will be different and clinical performance is highly case-specific, meaning clinical and workplace performance varies from one case to the other, from one situation to another, and from one CanMEDS role to another. Contextual factors may vary from quiet to busy, functional to dysfunctional teams, and so on.

Variability in assessor judgements

Assessing complex performance requires judgement on the part of the assessors, and assessors vary in their judgements, even when based on the same evidence.

Some of this variation is meaningful. Specifically, different assessors may focus on different aspects of performance, and may value different things as indicators of good care, thus providing a richer overall picture of performance. Having multiple assessors, including assessors with different professional backgrounds and roles can therefore be beneficial.

Some of this variation can be viewed as random error, or ‘noise’. For example, different assessors may interpret a learner’s behaviour in different ways. For example, a learner crossing their arms might be interpreted as nervous versus un-empathetic. Although these inferences are largely subconscious, assessors should be encouraged to consider initial judgements as hypotheses that require testing. For example, assessors could discuss what they saw with the learners and ask questions about what they were thinking or feeling at the time. When assessors supervise learners over a prolonged period, patterns of behaviour under different circumstances may become clearer.

Another way in which assessors generate ‘noise’ in their judgements is in their varying interpretation of scale points – they may agree on a narrative description of a learner and how it ranks compared to descriptions of other learners, yet vary when the judgements are translated into numbers. Narrative descriptions may therefore be more beneficial, not just because they are easier for learners to understand and thus provide better feedback, but also because they may be interpreted by other assessors in a more consistent way. A compromise way of representing judgements is the use of rubrics such as milestones, which include clear descriptions of performance categories. They are easier to combine than purely narrative judgements, yet reduce the variability of interpretation involved in rating scales. Finally, faculty development may foster increased agreement about performance levels.

Systematic bias or biases 

Finally, some of the variation can be systematic bias. Here are a few of the biases involved in workplace-based assessment:

  • the hawk/dove effect (some assessors tend to be more stringent/lenient than others)
  • the halo/horn effect (one good/bad aspect of performance leads to good/bad opinion of the performance as a whole)
  • availability and saliency biases when assessors judge overall performance based on an episode that they can easily or more vividly remember because it is recent, because something else triggered its recall, or because it was inherently more memorable (often because it was in some way extreme)
  • contrast/assimilation effects (when one learner’s performance is judged as unduly different/similar to that of other learners assessed at around the same time)
  • gender/ethnic/racial biases

Having multiple assessors is one way to mitigate biases. Encouraging assessors to document their findings is also an important strategy to mitigate availability and saliency biases. By keeping a record of their findings, assessors can also provide more detailed feedback, thus bolstering its credibility. Field notes combine the advantages of multiple observations, narrative descriptions, and regular documentation. 

Issues surrounding the provision of feedback will be addressed in a distinct Cell. Suffice it to say that learners are more likely to value and act upon feedback based in credible evidence provided by credible assessors whom they feel have their best interest at heart, and who can provide recommendations on next steps constructively.

Table 1: Methods of workplace-based assessment

Table 1 highlights the strengths and weaknesses of a few common workplace-based assessment methods.


Use to assess



Single Event

Clinical Evaluation Exercises (e.g. mini-CEX, P-MEX, T-MEX, O-SCORE)

Assess learner performances repeatedly using 15-20 minute observations of real patient interactions

Clinical performance

  • Can lead to reliable and credible assessments
  • Can lead to meaningful feedback
  • Requires time to observe learners
  • Some learners may initially feel uncomfortable being observed

Field notes

Narrative description of learner performance over several hours (e.g. in a clinic, during a shift)



Clinical performance


  • Narrative descriptions can be easier to interpret by learners and decision-makers (e.g. a competency committee) than numbers
  • Provide meaningful feedback



  • Relies heavily on assessors’ competence to write thoughtful comments
  • Time consuming to combine and interpret overall performance


In-training Evaluation Reports (ITER)

Scales may be accompanied by narrative descriptions of strength and weaknesses
Performance in the workplace
  • Low cost
  • Familiarity
  • Prone to availability and saliency biases

360o assessment = multisource feedback (MSF)

Measurement tools completed by multiple people in person’s sphere of influence (superiors, peers, subordinates, patients, families). Often associated with self- assessment


  • Multiple viewpoints
  • Provides rich feedback
  • Different ratings can be difficult to combine meaningfully
  • Assimilation of feedback may require coaching

Chart Review

Review of data recorded in patient charts and progress notes

Record-keeping Clinical reasoning
  • Feasibility, low cost
  • Wealth of information available
  • Reconstructed picture of encounters - Well synthesized notes can sometimes lead assessors in error : difficult to determine what clinical data learners failed to pick up on or mistakenly discarded
Portfolio Assessment
Learner develops a portfolio of qualitative or quantitative evidence of performance over time, accompanied by reflection on the learning journey

Clinical performance

Reflective skills
  • Provides a very broad overview of learning activities
  • Tracks progress
  • Provides a basis to plan future learning
  • Requires high level of trust between assessor and learner
  • Time consuming for learner and assessor
  • Can be perceived as “tick box” exercise, trivializing the process

Check for Understanding

1. What are the two main strengths of workplace based assessment?

2. Classify these statements as True or False and explain.

a) Portfolios are an example of workplace-based assessment

b) Workplace-based assessment is a poor method of assessment because it is subjective. True/False.

c) Chart reviews generate a wealth of data that can be hard to interpret.

3. Identify the weakness of the workplace-based assessment: Time, Lack of standardization, Variability in assessor judgements, Systematic bias or biases (BONUS: identify the bias).

a) One supervisor believes that only rarely should the top mark be given while most of the others give top marks for one or two top residents per year.

b) A clinical clerk complained that she got a lower mark because the patient she had to interview for her internal medicine rotation had comorbid mental health issues that made the interview much more challenging than most of the others her peers had to do.

c) The supervisor, due to urgent patient issues, was only able to observe part of the medical student-patient interaction but gave him a high mark anyway because he had clearly put the patient at ease.

d) One medical student was judged to have poor skills at establishing rapport with patients. Just before her turn to interview a patient a former psychiatric nurse turned medical student conducted an interview and set a very high bar for all the students who followed. As well, there was a Code Orange called during her interview which seemed to have upset the patient.


Please complete the following very short self-assessment on the objectives of this CORAL cell.

To what extent are you NOW able to meet the following objectives? (0 is not at all and 5 is completely)

1. Describe the uses and potential benefits of workplace-based assessment.

2. Given an assessment situation (mini-case) identify the weakness or weaknesses: Time, Lack of standardization, Variability in assessor judgements, Systematic bias or biases (BONUS: identify the bias).

To what extent WERE you able the day before beginning this CORAL Cell to meet the following objectives? (0 is not at all and 5 is completely)


1. Describe the uses and potential benefits of workplace-based assessment.

2. Given an assessment situation (mini-case) identify the weakness or weaknesses: Time, Lack of standardization, Variability in assessor judgements, Systematic bias or biases (BONUS: identify the bias).

Thank you for completing this CORAL Cell.

We are interested in improving this and other cells and would like to use your answers (anonymously of course) along with the following descriptive questions as part of our evaluation data.

Provide feedback on module

Thanks again, and come back soon!

The CORAL Cell Team


1 van der Vleuten CPM, Schuwirth LWT, Scheele F, Driessen EW, Hodges B. The assessment of professional competence: building blocks for theory development. Best Practice & Research Clinical Obstetrics & Gynaecology. 2010;24(6):703-19.

2 Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Medical Teacher. 2010;32(8):676-82.

Further reading:

Gingerich A, Kogan J, Yeates P, Govaerts M, Holmboe E. Seeing the 'black box' differently: assessor cognition from three research perspectives. Med Educ. 2014;48(11):1055-68.

 Gauthier G, St-Onge C, Tavares W. Rater cognition: review and integration of research findings. Med Educ. 2016;50(5):511-22.

 Hodges B. Assessment in the post-psychometric era: Learning to love the subjective and collective. Medical Teacher. 2013:1-5.


Author: Valérie Dory, McGill University
Series Editor: Marcel D’Eon, University of Saskatchewan

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