The Miller pyramid

Miller’s pyramid traditionally only has 4 stages but during recent discussions there have been suggestions that we should include 2 underpinning awareness levels that usually occur before we "know". The first two stages, ‘knows’ and ‘knows how’, can be assessed using the traditional assessment tools of written and oral tests. However, ‘knowing’ and ‘knowing how’ clearly do not necessarily extrapolate to the application of knowledge in the workplace.

To demonstrate clinical competence, assessment at levels 3 and 4 becomes more important, but also more challenging. Level 3, ‘shows how’, is currently assessed by practical examinations, observed long or short cases, or OSCE style examinations. However, the only way to assess level 4, ‘does’, is to observe the practitioner at work in the real world. In other words this measures our ability to perform.



The Miller Prism