Linking assessment to learning: a new route to quality assurance in medical practice R S Handfield-Jones, 1 K V Mann, 2 M E Challis, 3 S O Hobma, 4 D J Klass, 5 I C McManus, 6 N S Paget, 7 I J Parboosingh, 8 W B Wade 9 & T J Wilkinson 10 Background If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime’s storehouse of knowledge. Rather a doctor’s ongoing learning is a ÔjourneyÕ across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and com- munity issues. Objectives In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired perform- ance, define educational need and initiate educational action. Method To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. Conclusions We conclude by exploring the implications of this model for integrated medical services, highlight- ing the actions and directions that would be required of doctors, medical and professional organisations, uni- versities and other continuing education providers, credentialling bodies and governments. Keywords Clinical competence ⁄ *standards; physicians, family ⁄ *standards; education, medical, continuing ⁄ *standards; quality of health care ⁄ standards; *learning. Medical Education 2002;36:949–958 Introduction A well-known photograph of Sir William Osler shows him in characteristic pose at his desk, surrounded by a pile of books and papers – the paragon of medical virtue attending to his continuing medical education. 1 We know from the clinical method he espoused that Osler learned from his practice as well. Despite his example of making his practice his springboard for learning, medical educators have long focused on formal undergraduate and postgraduate education programmes as the princi- pal targets of their energy. It is noteworthy that it is only at these early stages of medical education that examina- tions, the hallmark of gravity of educational purpose, are imposed. Until recently, practising doctors have resisted the idea of ongoing practice assessments, possibly because of negative associations with such examinations. Nonetheless, the positive, and (some would say) neces- sary, role of assessment in learning needs to be embraced as a driving force of continuing professional develop- ment in promoting continuing competence. If such development is to be useful and reasonable, we need a model describing clinical practice that is 1 Department of Continuing Medical Education, College of Family Physicians of Canada, Mississauga, Ontario, Canada, 2 Division of Medical Education, Dalhousie University, Halifax, Nova Scotia, Canada, 3 Ufi Ltd, Sheffield, UK, 4 Department of General Practice, Centre for Quality of Care Research, University of Maastricht, Netherlands, 5 Quality Management Division, College of Physicians and Surgeons of Ontario, Toronto, Canada, 6 Department of Medical Education, University College, London, UK, 7 Department of Medicine and Psychological Medicine, Monash University, Melbourne, Victoria, Australia, 8 Royal College of Physicians and Surgeons of Canada, Canmore, Alberta, Canada, 9 Education Department, Royal College of Physicians, London, UK, 10 Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand Correspondence: Dr R Handfield-Jones, Continuing Medical Education, College of Family Physicians of Canada, 2630 Skymark Ave., Mississauga, Ontario, Canada. Tel.: 00 1 905Æ629Æ0900; Fax: 00 1 905Æ629Æ0893; E-mail: rhj@cfpc.ca Papers from the 10 th Cambridge Conference Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:949–958 949