Cross-cultural comparisons of assessment of clinical performance Mumtaz Patel & Steven Agius Global health care education is being promoted across national boundaries and it is imperative that cultural differences are acknowledged in terms of both curriculum delivery and assess- ment. 1,2 Assessment of clinical performance in experiential training pro- grammes relies heavily on judge- ments made by individual assessors and these may be influenced by socio-cultural factors. 3 Workplace- based assessment (WBA) has been used increasingly to assess clinical competence and performance in health care professionals, but is subject to an inherent problem of reliability associated with subjective bias in connection with inter- and intra-observer variability. 4 Bias and equivalence are two piv- otal concepts in the cross-cultural assessment of performance. 5 The use and adaptation of instruments in this setting must be considered with respect to cultural validity and specificity in order to optimise the utility of such instruments. 6 Bias and equivalence are two pivotal concepts in the cross-cultural assessment of performance Standardising assessment methods and improving assessor training could potentially minimise the subjective bias that arises in clini- cal assessment. 7 However, it is equally important that the percep- tions and processes underpinning assessors’ judgements and deci- sion making are understood, and these may vary with societal and cultural norms. 3 Quantitative rat- ing scales for WBA have been crit- icised in the context of performance assessment and qual- itative narratives are thought to be better for understanding opin- ions, but these lack uniformity in their interpretation. 8,9 There is a significant gap in knowl- edge of the cross-cultural use, validity and perceptions of meth- ods of assessing clinical perfor- mance outside Western countries. In this current edition of Medical Education, Wilbur and colleagues explore how clinical pharmacy pre- ceptors conceptualise levels of stu- dent performance across different cross-cultural contexts. 10 In a qual- itative interview-based study of 20 clinical preceptors in post-bacca- laureate doctoral pharmacy pro- grammes in Canada and the Middle East, seven major themes pertaining to how clinical precep- tors categorise levels of student performance were identified. 10 These included knowledge, team interaction, motivation skills, patient care, communication and professionalism. Interestingly, many more generic professional skills were noted to be of greater importance in clinical performance management than a pure knowledge base and clinical skills. Our own recent study noted that team assessment of behaviour and educational supervisor reports which provided a more global opinion were strongly predictive of poor performance in doctors. 11 This work again highlighted the importance of assessing more generic professional skills in evaluations of clinical performance. Wilbur et al. report that assessors judge performance comparatively (normatively) rather than against a set (criterion-referenced) stan- dard, 10 which confirms the find- ings of previous research. 12 This in itself introduces a greater degree of bias based on memory and personal experiences, which can be easily influenced. Assessors judge performance comparatively (normatively) rather than against a set (criterion-referenced) standard Interestingly, the study 10 did not find any difference in thresholds of how students were assessed in the different groups (Canadians, North Americans in the Middle East and Arab preceptors), which implies that there was less cul- tural bias in how competence was assessed. This study also showed that all clinical precep- tors, regardless of region, described students in a holistic fashion which emphasised traits associated with motivation, a pos- itive attitude and responding to feedback, 10 which could poten- tially negate some of the observed deficiencies. This Manchester, UK Correspondence: Mumtaz Patel, Health Education England North West, 3 Piccadilly Place, Manchester M1 3BN, UK. Tel: 00 44 161 276 4488; E-mail: mumtaz.patel@cmft.nhs.uk doi: 10.1111/medu.13262 348 ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2017 51: 342–350 commentaries