Composite reliability of workplace-based assessment of international medical graduates

Balakrishnan (Kichu) R Nair, Joyce MW Moonen-van Loon, Mulavana Parvathy, Brian C Jolly and Cees PM van der Vleuten
doi: 10.5694/mja17.00130


Objective: The fitness to practise of international medical graduates (IMGs) is usually evaluated with standardised assessment tests. The performance rather than the competency of practising doctors should, however, be assessed, for which reason workplace-based assessment (WBA) has gained increasing attention. Our aim was to assess the composite reliability of WBA instruments for assessing IMGs.

Design and setting: Between June 2010 and April 2015, 142 IMGs were assessed by 99 calibrated assessors; each was assessed in the workplace over 6 months. The IMGs completed 970 case-based discussions (CBDs), 1741 mini-clinical examination exercises (mini-CEX), and 1020 multi-source feedback (MSF) assessments.

Participants: 103 male and 39 female candidates from 28 countries (Africa, Asia, Europe, South America, South Pacific) in urban and rural hospitals of the Hunter New England Health region.

Main outcome measures: The composite reliability across the three WBA tools, expressed as the standard error of measurement (SEM).

Results: In our WBA program, a combination of five CBD and 12 mini-CEX assessments achieved an SEM of 0.33, greater than the threshold 0.26 of a scale point. Adding six MSF results to the assessment package reduced the SEM to 0.24, which is adequately precise.

Conclusions: Combining data from different WBA assessment instruments achieves acceptable reliability for assessing IMGs, provided that the panel of WBA assessment types are carefully selected and the assessors are calibrated.

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  • Balakrishnan (Kichu) R Nair1,2
  • Joyce MW Moonen-van Loon3
  • Mulavana Parvathy1
  • Brian C Jolly2
  • Cees PM van der Vleuten3

  • 1 Centre for Medical Professional Development, John Hunter Hospital, Newcastle, NSW
  • 2 University of Newcastle, Newcastle, NSW
  • 3 Maastricht University, Maastricht, The Netherlands


We thank Kathy Ingham and Lynette Gunning (Centre for Medical Professional Development, John Hunter Hospital, Newcastle) for data collection, Ian Frank (Australian Medical Council) for ongoing support and Tim Wilkinson (Christchurch Medical School) for valuable comments on the manuscript).

Competing interests:

No relevant disclosures.

  • 1. Tiffin PA, Illing J, Kasim AS, McLachlan JC. Annual Review of Competence Progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: national data linkage study. BMJ 2014; 348: g2622.
  • 2. Takahashi SG, Rothman A, Nayer M, et al. Validation of a large-scale clinical examination for international medical graduates. Can Fam Physician 2012; 58: e408-e417.
  • 3. Peile E. Selecting an internationally diverse medical workforce. BMJ 2014; 348: g2696.
  • 4. Neilson R. Authors have missed gap between theory and reality. BMJ 2008; 337: a1783.
  • 5. Kogan JR, Conforti LN, Iobst WF, Holmboe ES. Reconceptualizing variable rater assessments as both an educational and clinical care problem. Acad Med 2014; 89: 721-727.
  • 6. Miller A, Archer J. Impact of workplace based assessment on doctors’ education and performance: a systematic review. BMJ 2010; 341: c5064.
  • 7. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med 2007; 82: 542-547.
  • 8. Wilkinson JR, Crossley JG, Wragg A, et al. Implementing workplace-based assessment across the medical specialties in the United Kingdom. Med Educ 2008; 42: 364-373.
  • 9. van der Vleuten CP, Schuwirth LW. Assessing professional competence: from methods to programmes. Med Educ 2005; 39: 309-317.
  • 10. Bingham CM, Crampton R. A review of prevocational medical trainee assessment in New South Wales. Med J Aust 2011; 195: 410-412. <MJA full text>
  • 11. van der Vleuten CP, Schuwirth LW, Scheele F, et al. The assessment of professional competence: building blocks for theory development. Best Pract Res Clin Obstet Gynaecol 2010; 24: 703-719.
  • 12. Nair BK, Parvathy MS, Wilson A, et al. Workplace-based assessment; learner and assessor perspectives. Adv Med Educ Pract 2015; 6: 317-321.
  • 13. Nair BK, Searles AM, Ling RI, et al. Workplace-based assessment for international medical graduates: at what cost? Med J Aust 2014; 200: 41-44. <MJA full text>
  • 14. Moonen-van Loon JM, Overeem K, Donkers HH, et al. Composite reliability of a workplace-based assessment toolbox for postgraduate medical education. Adv Health Sci Educ Theory Pract 2013; 18: 1087-1102.
  • 15. Australian Medical Council. AMC clinical examination [website]. (accessed Sept 2015).
  • 16. Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med 2003; 138: 476-481.
  • 17. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE guide no. 31. Med Teach 2007; 29: 855-871.
  • 18. Davies H, Archer J, Southgate L, Norcini J. Initial evaluation of the first year of the Foundation Assessment Programme. Med Educ 2009; 43: 74-81.
  • 19. Moonen-van Loon JM, Overeem K, Govaerts MJ, et al. The reliability of multisource feedback in competency-based assessment programs: the effects of multiple occasions and assessor groups. Acad Med 2015; 90: 1093-1099.
  • 20. Swanson DB. A measurement framework for performance-based tests. In: Hart IR, Harden RM, editors. Further developments in assessing clinical competence. Montreal: Can-Heal, 1987; pp 13-45.
  • 21. Crossley J, Davies H, Humphries G, Jolly B. Generalisability: a key to unlock professional assessment. Med Educ 2002; 36: 972-978.
  • 22. Tighe J, McManus IC, Dewhurst NG, The standard error of measurement is a more appropriate measure of quality for postgraduate medical assessments than is reliability: an analysis of MRCP(UK) examinations. BMC Med Educ 2010; 10: 40.
  • 23. Norcini JJ. Standards and reliability in evaluation: when rules of thumb don’t apply. Acad Med 1999; 74: 1088-1090.
  • 24. Brennan RL. Generalizability theory. New York: Springer, 2001.
  • 25. Prescott-Clements L, van der Vleuten CP, Schuwirth LW, et al. Evidence for validity within workplace assessment: the Longitudinal Evaluation of Performance (LEP). Med Educ 2008; 42: 488-495.
  • 26. Weller JM, Misur M, Nicolson S, et al. Can I leave the theatre? A key to more reliable workplace-based assessment. Br J Anaesth 2014; 112: 1083-1091.
  • 27. Norcini J, Blank LL, Arnold GK, Kimball HR. The mini-CEX (clinical evaluation exercise): a preliminary investigation. Ann Intern Med 1995; 795-799.
  • 28. Lefroy J, Hawarden A, Gay SP, et al. Grades in formative workplace based assessment: a study of what works for whom and why. Med Educ 2015; 49: 307-320.
  • 29. Boursicot K, Etheridge L, Setna Z, et al. Performance in assessment: consensus statement and recommendations from the Ottawa conference. Med Teach 2011; 33: 370-383.


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