title: The use of clinical simulations in assessment.
abstract: BACKGROUND
  Simulation-based testing methods have been developed to meet the need for assessment procedures that are both authentic and well-structured. It is widely acknowledged that, although the authenticity of a procedure may be a contributing factor to its validity, authenticity alone never is a sufficient factor.
  
  
  OBJECTIVE
  In this paper we describe the mainstream development of various simulation-based approaches, with their strengths and weaknesses. The purpose is not to provide a review based on an extensive meta-analysis but to present crucial factors in the development of these methods and their implications for current and future developments.
  
  
  METHODS
  The description of these simulation-based instruments uses a subdivision according to the layers of Miller's pyramid. Written and computer-based simulations are aimed at measuring the 'knows how' layer, observation-based techniques such as standardised patient-based examinations and objective structured clinical examinations target the 'shows how' layer and performance practice measures assess performance at the 'does' layer.
  
  
  CONCLUSIONS
  In all simulations, case specificity was found to pose the most prominent threat to reliability, while too much structure threatened to trivialise the assessment. The conclusion is that authentic and reliable assessment is predicated on a wise balance between efficiency and adequate content sampling.
authors.affiliation: Department of Educational Development and Research, University of Maastricht, The Netherlands. l.schuwirth@educ.unimaas.nl
authors.forename: L W T
authors.initials: LW
authors.lastname: Schuwirth
authors.forename: C P M
authors.initials: CP
authors.lastname: van der Vleuten
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D003479:Curriculum; D004504:Education, Medical, Undergraduate / Q000379:methods* / Q000639:trends; D004521:Educational Measurement / Q000379:methods*; D006801:Humans; D016544:Patient Simulation