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Practical Guide to the Evaluation
of Clinical Competence
2nd Edition

i
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Practical Guide to the Evaluation
of Clinical Competence

2nd Edition

Eric S. Holmboe, MD, MACP, FRCP

Senior Vice President, Milestones Development and Evaluation
Accreditation Council for Graduate Medical Education
Chicago, Illinois;
Professor Adjunct
Yale University
New Haven, Connecticut;
Adjunct Professor of Medicine
Feinberg School of Medicine, Northwestern University
Chicago, Illinois

Steven J. Durning, MD, PhD

Professor of Medicine and Pathology
Department of Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland

Richard E. Hawkins, MD, FACP

Vice President, Medical Education Outcomes
American Medical Association
Chicago, Illinois
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

PRACTICAL GUIDE TO THE EVALUATION OF CLINICAL

COMPETENCE, ED. 2 ISBN: 978-0-323-44734-8

Copyright © 2018 Eric Holmboe, Richard Hawkins and Steven Durning, Published by Elsevier Inc. All rights
reserved.
For chapter 2 (Dr. Brian Clauser): Copyright © 2018, NBME. Published by Elsevier Inc. All Rights Reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing
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than as may be noted herein).

Notices

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Previous edition copyrighted 2008 by Mosby, an imprint of Elsevier Inc.

Library of Congress Cataloging-in-Publication Data

Names: Holmboe, Eric S., editor. | Durning, Steven J., editor. | Hawkins,
Richard E., editor.
Title: Practical guide to the evaluation of clinical competence / [edited by]
Eric S. Holmboe, Steven J. Durning, Richard E. Hawkins.
Description: 2nd edition. | Philadelphia, PA : Elsevier, [2018] | Includes
bibliographical references and index.
Identifiers: LCCN 2016048388 | ISBN 9780323447348 (pbk. : alk. paper)
Subjects: | MESH: Clinical Competence | Educational Measurement--methods |
Education, Medical, Graduate--standards | Competency-Based
Education--methods
Classification: LCC R837.A2 | NLM W 18 | DDC 616--dc23 LC record available at https://lccn.loc.gov/2016048388

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Preface
Assessment of health professionals across the continuum
of medical education and practice is essential for advanc-
ing high-quality and safe care for patients and the public.
Assessment of clinical competence is a core element of
professionalism and underlies effective professional self-­
regulation; it is essential for fulfilling our professional obli-
gation to assure the public that the graduates of medical
education training programs are truly prepared to enter the
next stage of education and/or practice. Despite substan-
tial attention to the quality and safety of healthcare over
the past 20 years, major deficiencies and concerns persist
in healthcare fields. The transformation of medical educa-
tion, and the education of all healthcare professionals, is
appropriately seen as part of the solution. Effective assess-
ment is a vital component of this transformation. First and
foremost, medicine is a service profession. As medical edu-
cators, it is vital we develop and use high-quality assessment
methods and systems in order to fulfill a primary obligation
to the public and patients we serve. Furthermore, effective
assessment provides the necessary data for robust feedback
and guidance to support professional growth and develop-
ment. Learners are entitled to no less; without assessment
and feedback the attainment of mastery, the ultimate goal
of outcomes-based education, is nearly impossible.
It has been nearly 10 years since the publication of the
first edition of this book, and much has changed during this
period. Competency-based medical educational (CBME)
models are now being implemented to varying degrees across
the globe in an effort to drive better outcomes of education
and by extension healthcare. The philosophical underpin-
nings of CBME are informing curricular and program-
matic assessment changes, accreditation and certification
approaches, and the credentialing of healthcare profes-
sionals. CBME has highlighted the importance of leverag-
ing more traditional methods of assessment while creating
substantial pressure and defining the need to advance other
methods of assessment, especially in the workplace. Fully
implemented, CBME frameworks embrace holistic and
constructivist approaches to assessment; successful assess-
ment programs will need to incorporate a diverse range of
educational and assessment theories and methods.
We are pleased to be able to share changes and advances
in assessment that have occurred since 2008. Many readers
let us know that one of the main benefits of the first edition
was the practical suggestions in each chapter that could be
implemented in training programs. We have attempted to
stay true to that philosophy by adding more supplemental
material and new chapters on assessing clinical reasoning in
the workplace, work-based procedural assessment, and feed-
back. All other chapters have undergone extensive revision
to be up-to-date and practical.
The three of us have spent much of our professional lives
thinking, learning, and then teaching about assessment.
Like many of you, much of our initial learning was through
trial and error, occurring as a result of being assigned posi-
tions of responsibility in determining the competence of
students and residents in internal medicine. We have also
had the privilege to work within national organizations
involved in the assessment of physicians across the contin-
uum. Assessment is not routinely seen by physicians and
other health professionals as a welcome activity, especially
when it comes from an external entity. Yet without assess-
ment feedback is almost impossible and continuous profes-
sional growth is difficult. We hope by sharing part of our
own journey through this textbook we can help the reader
address important assessment challenges they are facing in
their own work context and also contribute to larger con-
versations around assessment as a mechanism to improve
healthcare quality and safety.
The primary purpose of this book is to provide a practi-
cal guide to developing assessment programs using a sys-
tems lens. No single assessment method is sufficient to
determine something as complex as clinical competence.
Educators will need to develop programs of assessment by
choosing the optimal combination of methods, based on
the best evidence available, for their local context. This book
has been organized around the various assessment methods
and instruments and how individuals with responsibilities
for assessment can apply these methods and instruments
in their own setting. We have provided an overview of key
educational theories where applicable to help the reader
understand how best to use the assessment method and its
purpose. Each chapter provides information on the strengths
and weaknesses of the assessment method, along with infor-
mation about specific tools. Many chapters provide examples
of assessment instruments along with suggestions on faculty
development and effective implementation of the assess-
ment method. Each chapter also contains an annotated
­bibliography of helpful articles for additional reading.
The first chapter provides an overview of basic assess-
ment principles with a focus on the rise and impact
of competency-based approaches to achieve outcomes.
v
vi Preface
Chapter 2 provides a useful primer on key theories
and aspects of psychometrics, a discipline that remains
essential to effective assessment. Chapter 3 explores the
evolving approaches to the use of rating scales, a com-
mon component of assessment forms and surveys, high-
lighting the importance of appropriate frameworks and
anchors. Direct observation in the workplace, especially
of clinical skills, is the focus of Chapter 4 with multiple
practical suggestions on how to better prepare faculty
in this essential assessment skill. Chapter 5 explores the
assessment of clinical skills with standardized patients,
another form of direct observation in controlled settings.
Chapter 6 provides an extensive overview on the effective
use of the traditional written, standardized tests of medical
knowledge and clinical reasoning, still an essential part of
an assessment program. However, the need for high-quality
assessment of clinical reasoning in the workplace has grown
in importance with the recognition of the persistent and
pernicious problem of diagnostic and therapeutic errors in
clinical practice. This is the focus of Chapter 7, a new chap-
ter for this edition. Another new addition, Chapter 8, covers
the assessment of procedural competence in the workplace,
another growing area of interest for medical educators in an
era of patient safety concerns.
Chapter 9 addresses the importance of assessing evi-
dence-based practice, an essential competency in a time of
rapidly expanding medical knowledge and growing use of
clinical decision support at the point of care. Chapter 10 has
been extensively revised and now focuses on the multiple
ways to assess performance in clinical practice using quality
and safety measures. The growing use of these measures is
now an established part of medical practice across the globe.
Chapter 11 provides guidance on the effective use of multi-
source feedback, an approach essential to patient-centered
care and interprofessional practice.
Chapter 12 is a complement to Chapter 5, covering the
growing field of simulation outside standardized patients.
Simulation, depending on the discipline, should increas-
ingly become a standard component of an assessment pro-
gram. Chapter 13 is a new chapter on practical approaches
to feedback. This chapter was added because no assessment
system can be fully effective without robust feedback.
The final three chapters help the reader “put it all together.”
Portfolios, covered in Chapter 14, offer a comprehensive
approach to supporting an assessment program. The chapter
provides practical advice on how to design and implement
portfolios. Chapter 15 provides a systematic approach to
working with the dyscompetent learner, i.e., the learner in
difficulty. These learners require an assessment program and
systematic approach using multiple assessment methods.
The final chapter, Chapter 16, covers the important role of
programmatic evaluation as part of an effective educational
program. Newer concepts and approaches to programmatic
assessment are provided.
Effective assessment requires a multifaceted approach
using a combination of assessment methods. This is the
rationale behind the organization and design of this book.
Effective assessment also depends upon collaboration among
a team of faculty and other educators; thus any change to an
assessment system must include not only buy-in from oth-
ers, but also the investment to train educators to use assess-
ment methods and tools effectively. In a CBME system, this
must also include the learners as “active agents” in their own
learning and assessment. Interprofessional faculty, program
leaders, and learners need to work together to co-create and
co-produce assessment to maximize educational, and ulti-
mately, clinical outcomes.
It is essential to remember the true assessment instru-
ment is the individual using it, not the instrument itself.
Assessment tools are only as good as the individual using
them. If done well, assessment can have a profoundly posi-
tive effect on patients, learners, and faculty. That has not
changed since 2008 and likely never will. Nothing can be
more satisfying than knowing each and every one of your
graduates is truly ready to move to the next career level.
The public expects no less, and we should expect no less
from ourselves. In that spirit, we welcome comments from
you, the reader, on how we can improve upon this book.
Eric S. Holmboe
Steven J. Durning
Richard E. Hawkins
Contributors

John R. Boulet, PhD Richard E. Hawkins, MD, FACP

Vice President, Research and Data Resources Vice President, Medical Education Outcomes
Foundation for Advancement of International Medical American Medical Association
Education and Research Chicago, Illinois
Educational Commission for Foreign Medical Graduates
Philadelphia, Pennsylvania Eric S. Holmboe, MD, MACP, FRCP
Senior Vice President, Milestones Development and
Carol Carraccio, MD Evaluation
Vice President Accreditation Council for Graduate Medical Education
Competency Based Assessment Programs Chicago, Illinois;
American Board of Pediatrics Professor Adjunct
Chapel Hill, North Carolina Yale University
New Haven, Connecticut;
Brian E. Clauser, EdD Adjunct Professor of Medicine
Vice President Feinberg School of Medicine, Northwestern University
Center for Advanced Assessment Chicago, Illinois
National Board of Medical Examiners
Philadelphia, Pennsylvania William Iobst, MD
Vice Dean and Vice President for Academic Affairs
Daniel Duffy, MD Professor of Medicine
Landgarten Chair of Medical Leadership Geisinger Commonwealth School of Medicine
Department of Internal Medicine Scranton, Pennsylvania
Oklahoma University School of Community Medicine
Tulsa, Oklahoma Jennifer R. Kogan, MD
Professor of Medicine
Steven J. Durning, MD, PhD Assistant Dean, Faculty Development
Professor of Medicine and Pathology Director of Undergraduate Education, Department of
Department of Medicine Medicine
Uniformed Services University of the Health Sciences Perelman School of Medicine at the University of
Bethesda, Maryland Pennsylvania
Philadelphia, Pennsylvania
Michael L. Green, MD
Professor of Medicine Jocelyn M. Lockyer, PhD
Department of Internal Medicine Professor of Community Health Sciences
Associate Director for Student Assessment Senior Associate Dean of Education
Teaching and Learning Center Cumming School of Medicine
Yale University School of Medicine University of Calgary
New Haven, Connecticut Calgary, Alberta, Canada

Stanley J. Hamstra, PhD Melissa J. Margolis, PhD

Vice President, Milestones Research and Evaluation Senior Measurement Scientist
Accreditation Council for Graduate Medical Education National Board of Medical Examiners
Chicago, Illinois Philadelphia, Pennsylvania

vii
viii Contributors

Neena Natt, MD Ross J. Scalese, MD

Associate Professor Associate Professor of Medicine
Vice Chair Education Director of Educational Technology Development
Division of Endocrinology, Diabetes, Metabolism, Michael S. Gordon Center for Research in Medical
Nutrition Education
Mayo Clinic University of Miami Miller School of Medicine
Rochester, Minnesota Miami, Florida

Patricia S. O’Sullivan, EdD David B. Swanson, PhD

Director
Research and Development in Medical Education
Center for Faculty Educators, School of Medicine
Professor of Medicine
University of California San Francisco
San Francisco, California
Vice President of Academic Affairs
American Board of Medical Specialties
Chicago, Illinois;
Professor (Honorary) of Medical Education
University of Melbourne
Victoria, Australia

Louis N. Pangaro, MD, MACP Olle ten Cate, PhD

Professor and Chair Professor of Medical Education
Department of Medicine Center for Research and Development of Education
Uniformed Services University of the Health Sciences University Medical Center Utrecht
Bethesda, Maryland Utrecht, the Netherlands

Joan M. Sargeant, PhD

Professor
Faculty of Medicine
Division of Medical Education
Department of Community Health and Epidemiology
Dalhousie University
Halifax, Nova Scotia, Canada;
Adjunct Professor
School of Education
Acadia University
Wolfville, Nova Scotia, Canada
Acknowledgments

In memory of my incredibly supportive parents, Dr.
Kenneth C. and Mrs. Bette M. Holmboe.
All my love and appreciation to my wife and best friend,
Eileen Holmboe, and my two amazing children who bring
so much joy, Ken and Lauren.
Eric S. Holmboe
Much love and gratitude to my mother, Jacqueline
Hawkins, and my partner, Margaret Jung, for their support
and encouragement.
Richard E. Hawkins

To my wife of 25 years, Kristen, and my two wonder-

ful sons, Andrew and Daniel, for their love and support.
To my parents and my in-laws for their wisdom and
encouragement.
Steven J. Durning

Dedication

We also wish to acknowledge the talent and dedication of

the authors whose effort and expertise resulted in this book.
We also wish to thank the countless trainees and faculty that
we have worked with over the years who continue to inspire
and challenge us.
Eric S. Holmboe, Steven J. Durning,
Richard E. Hawkins

ix
This page intentionally left blank

     
Contents
1 Assessment Challenges in the Era of
Outcomes-Based Education, 1
Eric S. Holmboe, Olle ten Cate, Steven J. Durning, and
Richard E. Hawkins
2 Issues of Validity and Reliability for
Assessments in Medical Education, 22
Brian E. Clauser, Melissa J. Margolis, and David B. Swanson
3 Evaluation Frameworks, Forms, and Global
Rating Scales, 37
Louis N. Pangaro, Steven J. Durning, and Eric S. Holmboe
4 Direct Observation, 61
Jennifer R. Kogan and Eric S. Holmboe
5 Direct Observation: Standardized Patients, 91
John R. Boulet, Neena Natt, and Richard E. Hawkins
6 Using Written Examinations to Assess Medical
Knowledge and Its Application, 113
David B. Swanson and Richard E. Hawkins
7 Assessing Clinical Reasoning in the
Workplace, 140
Eric S. Holmboe and Steven J. Durning
8 Workplace-Based Assessment of Procedural
Skills, 155
Stanley J. Hamstra
9 Evaluating Evidence-Based Practice, 165
Michael L. Green
10 Clinical Practice Review, 184
Eric S. Holmboe and Daniel Duffy
11 Multisource Feedback, 204
Jocelyn M. Lockyer
12 Simulation-Based Assessment, 215
Ross J. Scalese
13 Feedback and Coaching in Clinical Teaching
and Learning, 256
Joan M. Sargeant and Eric S. Holmboe
14 Portfolios, 270
Patricia S. O’Sullivan, Carol Carraccio, and Eric S. Holmboe
15 The Learner With a Problem or the Problem
Learner? Working With Dyscompetent
Learners, 288
William Iobst and Eric S. Holmboe
16 Program Evaluation, 303
Richard E. Hawkins and Steven J. Durning
xi
Video Contents
4 Direct Observation
4.1 Medical Interviewing: Level 1 History Taking
4.2 Medical Interviewing: Level 2 History Taking
4.3 Medical Interviewing: Level 3 History Taking
4.4 Physical Examination: Level 1
4.5 Physical Examination: Level 2
4.6 Physical Examination: Level 3
4.7 Counseling: Level 1
4.8 Counseling: Level 2
4.9 Counseling: Level 3
4.10 How Faculty Should Conduct an Effective
­Observation
4.11 Medical Interviewing: Level 1
4.12 Medical Interviewing: Level 2
xii
4.13 Medical Interviewing: Level 3
4.14 Physical Examination: Level 1
4.15 Physical Examination: Level 2
4.16 Physical Examination: Level 3
4.17 Informed Decision Making: Level 1
4.18 Informed Decision Making: Level 2
4.19 Informed Decision Making: Level 3
13 Feedback and Coaching in Clinical
Teaching and Learning
13.1 An Evidence-Based 4-Stage Model for Facilitating
Reflective Feedback and Coaching for Change:
R2C2
1
Assessment Challenges in the Era of
Outcomes-Based Education
ERIC S. HOLMBOE, MD, MACP, FRCP, OLLE TEN CATE, PHD,
STEVEN J. DURNING, MD, PHD, AND RICHARD E. HAWKINS, MD, FACP

CHAPTER OUTLINE References

Appendix 1.1: Developing an Entrustable Professional
The Rise of Competency-Based Medical Education
Activity
Outcomes and Competency-Based Medical Education
Appendix 1.2: Entrustable Professional Activities,
A Brief History of Assessment Competencies, and Milestones: Pulling It All Together
Drivers of Change in Assessment
Accountability and Quality Assurance
Quality Improvement Movement
Technology The Rise of Competency-Based Medical
Psychometrics Education
Qualitative Assessment and Group Process
Framework for Assessment
Despite major biomedical and technical advances, medi-
cal care across the globe continues to suffer from perni-
Dimension 1: Competencies
cious quality and safety gaps that result in substantial
Dimension 2: Levels of Assessment
harm and ineffective care for too many patients each
Miller’s Pyramid
The Cambridge Model
year.1,2 In 2001, the Institute of Medicine codified the
six aims of quality: care that is effective, efficient, safe,
Dimension 3: Assessment of Progression
patient centered, timely, and equitable.3 More recently,
Criteria for Choosing a Method the triple aim of quality in patient experience (defined
Elements of Effective Faculty Development by the six aims), health of a population, and cost stew-
Overview of Assessment Methods ardship has become the overarching driving framework
Traditional Measures for the United States and other health care systems.4 Yet
Methods Based on Observation
data from multiple sources, such as the Organization for
Economic Cooperation and Development (OECD), the
Simulation
World Health Organization (WHO), and the Common-
Work
wealth Fund (CMWF), demonstrate persistent problems
New Directions in Assessment in morbidity and mortality that are amenable to better
Milestones and safer health care delivery.5 Although a number of
Entrustable Professional Activities factors contribute to this state of affairs, many medical
Combining Milestones and Entrustable Professional educators and policymakers accept the premise that the
Activities medical education enterprise bears some responsibility
Entrustable Professional Activities – Competencies – Skills through insufficient preparation of trainees for 21st-cen-
Entrustable Professional Activities Across the Continuum tury practice.6 In conjunction with these concerns about
and Nested Entrustable Professional Activities health care quality and safety has been the growing focus
Entrustment Decision Making as Assessment on the outcomes of education. Specifically, educators are
Systems of Assessment (See Chapter 16.) now most concerned with the abilities of a graduate rather
than whether a trainee simply completes a prescribed edu-
Conclusion
cational program.7 These and other factors have led to the
Acknowledgment global spread of outcomes-based medical education using

1
2 CHA P T ER 1 Assessment Challenges in the Era of Outcomes-Based Education
competencies as a foundational outcomes framework for
educational programs.7–11
In 1978, McGaghie and colleagues described a ratio-
nale for an approach to medical education founded on the
acquisition of defined competencies. “The intended output
of a competency-based programme,” they wrote, “is a health
professional who can practise medicine at a defined level of
proficiency, in accord with local conditions, to meet local
needs.”8 Educational leaders and policymakers worldwide
produced multiple reports lamenting that medical educa-
tion systems were not producing physicians with the abili-
ties needed to meet the complexities of modern practice,
leading to the realization that reforms in undergraduate,
graduate, and continuing medical education were urgently
needed. In the United States, several recent reviews call
attention to the inadequate preparation of our graduates to
practice effectively in our evolving health care systems.12–14
This context and other factors ultimately led to the devel-
opment of competency frameworks in several countries as
part of initiatives to implement competency-based medical
education (CBME) to achieve better educational and clini-
cal care outcomes. The first iteration of the Canadian Medi-
cal Education Directions for Specialists (CanMEDS) Roles
by the Royal College of Physicians and Surgeons of Can-
ada was produced in 1996.15,16 Recognizing similar needs
and issues, the Accreditation Council of Graduate Medical
Education, the American Board of Medical Specialties, the
Institute of Medicine, the General Medical Council of the
United Kingdom, the Royal Australasian College of Sur-
geons, the Dutch College of Medical Specialties, and other
national professional entities produced competency frame-
works.17–21 Two key features of these competency projects
stand out. One is a redefinition of the doctor to include
many more important and relevant abilities and constructs
beyond medical knowledge and technical skill that had been
dominating training in the previous decades. The other fea-
ture is the intention to better monitor doctors in training
and to ensure they meet predefined competency standards
upon graduation to unsupervised practice.7,22
Since the publication of the first edition of this book
in 2008, a number of major reports and initiatives have
sought to move CBME toward broader implementa-
tion. The International CBME Collaborators, a group of
medical educators and leaders convened by the Royal Col-
lege of Physicians and Surgeons of Canada, produced a
series of articles on the history, concepts, and challenges
to implementation of competency-based medical educa-
tion, including needed changes to assessment, across the
continuum of medical training.15,16,23–25 In the same year,
Frenk and a group of international leaders published an
influential position paper in The Lancet on the need to
accelerate transformation in medical education, grounded
in the principles of CBME.6 Finally, on the 100th anni-
versary of the Flexner report (1910), the Carnegie Founda-
tion released recommendations for medical education that
embraced many of the key principles and goals of CBME.9
All of these reports have highlighted the critical need for
better assessment.
The primary purpose of this second edition is to pro-
vide practical guidance to educators and program leaders
on the “front lines” for building and implementing better
programs and systems of assessment using the best evidence
and information available. Assessment is fundamental and
essential for effective learning and for achieving both desired
educational and clinical outcomes. CBME is part of the lat-
est phase on what should be a continuous commitment to
improve educational programs and by extension the qual-
ity and safety of care patients and populations receive. This
introductory chapter will present an overview of the drivers
of change in the assessments used during clinical education,
frameworks for such assessment, criteria for choosing assess-
ment methods, elements of an effective faculty development
effort, and the new concepts of competencies, milestones,
and entrustable professional activities now being used to
facilitate change and improvement in medical education.
Before moving on to fundamental issues of assessment in a
CBME world, we will first review some key definitions and
elements of CBME.
Outcomes and Competency-Based Medical
Education
A focus on the educational process has now shifted to an
emphasis on what a physician is able to actually do at the end
of training and at important junctures during the training
process. Competencies have become a primary mechanism
for defining the educational outcomes. Outcomes-based
education starts with a specification of the competencies
expected of a physician, and these requirements drive the
content and structure of the curriculum, the selection and
deployment of teaching and learning methods, the site of
training, and the nature of the teachers. Assessment plays a
central role in determining whether students and residents
have actually achieved the competencies that have been
specified and whether the educational program has been
efficacious. CBME highlights the importance of integrating
curriculum and assessment; they should not be independent
activities but rather inform each other as part of an overall
educational system and program of assessment. This change
in thinking and the need to assess the diverse competencies
of the physician have been important factors in the develop-
ment of new methods of assessment, especially work-based
assessments covered in detail throughout this book.
CBME is an outcomes-focused approach to and philoso-
phy of designing the explicit developmental progression of
health care professionals to meet the needs of those they
serve. Among its fundamental characteristics (Box 1.1) is
a shift in emphasis away from time-based programs based
solely on exposure to experiences such as clinical rotations
in favor of an emphasis on needs-based graduate outcomes,
authenticity, and learner-centeredness.11,26 As defined
by Frank and colleagues, CBME is “an outcomes-based
approach to the design, implementation, assessment, and
evaluation of medical education programs, using an orga-
nizing framework of competencies.”11 Although outcomes
 CHAPTER 1
• BOX 1.1    Fundamental Characteristics of
Competency-Based Medical Education
Graduate outcomes in the form of achievement of predefined
desired competencies are the goals of competency-based
medical education (CBME) initiatives. These are aligned with the
roles graduates will play in the next stage of their careers.
These predefined competencies are derived from the needs of
patients, learners, and institutions and organized into a coherent
guiding framework.
Time is a resource for learning, not the basis of progression
of competence (i.e., time spent on a ward is not the marker of
achievement).
Teaching and learning experiences are sequenced to facilitate
an explicitly defined progression of ability in stages.
Learning is tailored to the learner’s individual progression in
some manner.
Numerous direct observations and focused feedback
contribute to effective learner development of expertise.
Assessment is planned, systematic, systemic, and integrative.
are now the primary driver, that does not mean educational
structures and processes are not important. The famous
Donabedian equation for quality, Structure × Process = Out-
comes, highlights that good outcomes depend on effective
structures and processes.27 However, we are also learning
that the relationship between structure and process is quite
complex and nonlinear in its actual execution.28 Chapter 16
provides helpful guidance on how to embrace complexity as
part of program design and evaluation. Assessment is a criti-
cal part of the complex interaction between structure and
process in an educational program.
Assessment is an essential activity (i.e., process) that can
be used to demonstrate outcomes of interest. This is not a
new insight—assessment has always been critically impor-
tant in any educational endeavor. However, the problems
with assessment in medical education, and in general all of
health professions education, have been long-standing and
persistent, such as lack of direct observation of learner per-
formance and meaningful feedback, overreliance on testing
for assessment of medical knowledge, lack of attention to
other essential competencies that address our graduates’
abilities to function effectively in our health care systems
such as interprofessional teamwork and quality improve-
ment, and ineffective use of assessment methods and tools
by faculty, to name a just a few. In this introductory chapter,
we will first explore fundamental issues in assessment, fol-
lowed by recent attempts to more effectively operationalize
competencies through milestones and entrustable profes-
sional activities, and then close with the importance of cre-
ating a program of assessment. Throughout this chapter we
will refer the reader to other chapters in the book to help the
reader create and revise their own program of assessment.
A Brief History of Assessment
Through the early 1950s, physicians were assessed in lim-
ited ways.29 Medical knowledge was evaluated with essays
and other open-ended question formats that were graded by
Assessment Challenges in the Era of Outcomes-Based Education 3
an instructor. Clinical skill and judgment were tested using
an oral examination that often required the student to go
to the bedside, gather patient information, and present it
along with a diagnostic list and treatment plan to one or
more examiners who asked questions. Because these were
the only generally accepted methods available, they were
applied to most assessment problems even if they were not
completely suitable to the task. That may have been accept-
able in a time when supervisors had much more control over
the health care process and had natural checks of everything
learners reported. Over the past decades health care has
become too complex to warrant this type of “on-the-fly,” ad
hoc approach. For example, lengths of stay in hospitals have
dropped dramatically and faculty have multiple competing
responsibilities.
From that point to the present, there have been exten-
sive changes in the way assessment is conducted. Meth-
ods have proliferated, as have the requirements for their
appropriate use. Much progress has been made in the
assessment of medical knowledge with a variety of written
and computer-based techniques offering reliable and valid
results (see Chapter 6). In the last few decades, consid-
erable gains have been made in defining and enhancing
the psychometric qualities of objective structured clinical
examinations (OSCEs), particularly related to their use
in high-stakes examinations (see Chapter 5). However,
assessment in the context of learners caring for patients
in clinical units (i.e., wards, operating theater, ambulatory
clinic) has lagged to some degree, especially in the areas of
clinical skills, interprofessional teamwork, and quality and
safety of care.24,30
Equally important, the methods that have been devel-
oped to support clinical education often rely on faculty
who are inexperienced in their use, do not share common
standards or shared mental models of the competencies of
importance, and have not been trained to apply them in a
consistent fashion. In addition, faculty now experience sub-
stantial time pressures, more learner and patient handoffs,
higher degrees of comorbidity among hospitalized patients,
and increasing personal clinical responsibilities. Perhaps
more concerning are recent findings that one of the prin-
cipal drivers of faculty assessment relates to their own clini-
cal skills, with a number of studies highlighting important
deficiencies in practicing physician clinical skills such as
medical interviewing, physical examination, and communi-
cation skills.31,32 Finally, many of the faculty are also being
asked to assess and judge competencies, such as care coor-
dination, patient safety, and use of information technology,
areas in which they themselves were never formally trained.
Compounding this state of affairs has been the lack of effec-
tive faculty development approaches and models to address
these new clinical and educational methods.33
Drivers of Change in Assessment
The increased public focus on the medical education enter-
prise is important; medical education should always be in
service of individual patients and the public. Using a service
4 CHA P T ER 1 Assessment Challenges in the Era of Outcomes-Based Education
logic can help educators develop assessment programs that
meet public, patient, and learner needs.34 Many programs
globally are implementing curricular changes that embrace
competencies and outcomes, supported by improvements
in technology, psychometrics, and evolving work-based
assessment approaches that increasingly incorporate more
qualitative techniques and systematic judgment.
Accountability and Quality Assurance
The movement to competency-based medical education
has been accompanied by significant efforts to enhance
the accountability of physicians.3 Motivated by the need
to improve quality and safety, and in part by high-pro-
file cases such as those involving Michael Swango in the
United States and Howard Shipman in the United King-
dom in the 1990s, the public has continued to pressure
medicine to increase its level of oversight and eliminate the
“bad apples.”35,36 Medical educators are also more keenly
aware that too many trainees graduate with substantial
deficiencies in foundational knowledge and clinical skills
and more recently have become aware of deficiencies in
competencies important to succeed in our health care sys-
tems.12–14,37 Effective quality assurance depends on robust
assessment programs and is critically important to ensure
that graduates of medical education programs are truly
ready for promotion to the next stage and ultimately unsu-
pervised practice. Promoting trainees who lack compe-
tence erodes, if not destroys, the trust between the medical
profession and the public.
Quality Improvement Movement
At the same time, there has been a variety of efforts focused on
continuously improving the quality of health care.4,27,38–41
These efforts have relied on methods devised by workers in
the field of quality management science and, in some cases,
used successfully in industry for over 60 years to drive con-
tinuous improvement in health care and now increasingly
in medical education programs. Central to quality improve-
ment is assessment—it is very hard to improve without
meaningful measurement and data. It offers a means of
identifying those whose overall performance is well below
standard and also identifying areas for improvement for
those who are generally performing adequately, helping to
drive the continuous quality improvement process. These
developments have helped to fuel the creation of several
new methods of assessment and to increase the use of other
methods already available. For example, the milestones
initiative, an attempt to better describe competencies in
narrative, developmental terms in the United States, uses
the principles of continuous quality improvement as part
of its foundation to improve graduate medical education.
The milestones initiative can be viewed through the lens
of “action- or practice-based research” to learn and develop
evidence over time.42 There is no single “holy grail” of
assessment. All assessments have strengths and weaknesses,
and programs need to build in ongoing evaluation of their
assessment activities. (See Chapter 16.)
Technology
Over the past 50 years, the availability of increasingly
sophisticated technology has changed the testing of medi-
cal knowledge and judgment in fundamental ways.43,44 The
introduction of the computer heralded an era of large-scale
testing by encouraging the use of multiple-choice ques-
tions (MCQs), the answers to which could be scanned by
machine, turned into scores, and then reported in an effi-
cient and objective fashion.
More recently, the intelligence of the computer has
improved assessment in two ways:
1. On the one hand, it has enabled the application of signif-
icant psychometric advances to the assessment of medical
knowledge. Specifically, the computer’s intelligence has
improved efficiency by allowing the selection of ques-
tions that are targeted to the ability of particular examin-
ees. Sequential testing and adaptive testing permit gains
in efficiency and precision.
2. On the other hand, it has improved the assessment of
higher cognitive abilities, including clinical reasoning, by
permitting the use of interactive item formats that more
closely simulate the types of judgments physicians need
to make in practice. (See Chapter 6.)
Although the impact of technology on assessment of
clinical skills has been slower to develop, advances in simu-
lation and computer technology have led to the develop-
ment of approaches and tools that recreate aspects of the
clinical encounter with considerable fidelity. These methods
have a growing impact on assessment, especially in the area
of procedural skills, where mastery models are beginning to
gain traction.45–48
Finally, technology, especially through smartphone and
tablet applications, is beginning to change the way assess-
ment data is obtained and processed. For example, tools
designed for assessment through direct observation are
increasingly being converted into smartphone applica-
tions.46,47 Learning management systems, increasingly used
by programs, are also beginning to incorporate mobile apps
into their platforms.49 These portable applications hold sub-
stantial promise to reduce the data collection burden while
guiding the assessment activity of the faculty to attend to
critical competencies.
Psychometrics
At the same time that the technology has improved, there
have been significant advances in psychometrics, the basic
science of assessment. Classical test theory, prominent from
the turn of the 20th century, has gradually given way to
measurement models based on strong assumptions about
test items and examinees. The family of item response the-
ory models now makes it possible to produce equivalent
scores even when examinees take tests made up of different
 CHAPTER 1
questions.50 They also support the computer-based admin-
istration of examinations that are tailored to the ability level
of individual test-takers; this allows tests to be shortened by
as much as 40%.51 The ability to shorten tests has cost and
validity implications; less test material exposure decreases
the likelihood that future examinees are familiar with exam-
ination content.52 Generalizability theory makes it possible
to identify how much error is associated with different fac-
ets of measurement (e.g., raters, patients).53 Based on this
information, assessments can be prospectively designed to
make the best use of resources, such as faculty time, while
maintaining the reliability of the results.
In addition to these major developments, there have
been a number of other advances. For example, there are
a variety of systematic methods available for setting stan-
dards on tests and for identifying when test questions are
biased against particular groups of examinees.2,54,55 Test
development methods have gotten better, as have the means
for judging whether particular items are working properly.
Overall, these advances have improved both the quality and
efficiency of assessment.
Qualitative Assessment and Group Process
Although advances in psychometrics have clearly helped to
improve assessment in medical education and will remain
a core science for assessment, many have noted limita-
tions of the traditional psychometric approach in today’s
complex clinical and educational environment.56 Often
referred to as “qualitative” or “narrative” assessment, use
of the written word has grown in importance. For exam-
ple, many of the new smartphone apps contain natural
language processing capability that allow for the capture
of narrative assessment and feedback through dictation.
Milestones, discussed in more detail later, are more robust
narrative descriptors of stages of development, bringing
both quantitative and qualitative aspects of measurement
more closely together.48
TABLE
1.1 The Competencies of Physicians as Described by Four Organizations
CanMEDS GMC
Medical expert Good clinical care
Communicator Maintaining good medical practice
Collaborator Teaching and training
Appraising and assessing
Leader Relationships with patients
Health advocate Working with colleagues
Scholar Probity
Professional Health
ABMS, American Board of Medical Specialists; ACGME, Accreditation Council for Graduate Medical Education; CanMEDS, Canadian Medical Education Direc-
tions for Specialists; GMC, General Medical Council (UK); IOM, Institute of Medicine.
Assessment Challenges in the Era of Outcomes-Based Education 5
Group process, commonly through entities called clini-
cal competency committees, has also become an impor-
tant part of the assessment process and programs. Effective
group process can lead to better judgments around com-
petence.57–59 Finally, qualitative research techniques have
been shown to have value in judging aggregate assessment
information, such as that contained within a portfolio (see
Chapter 14). Again, a rigorous approach to application
of qualitative research techniques and principles helps to
enhance the reliability and validity of judgments.60–62
Framework for Assessment
As methods of assessment have proliferated, so has the
need to use them efficiently and to combine them into a
system of assessment. Developing, implementing, and
sustaining effective systems for the assessment of clinical
competence in medical school, residency, and fellowship
programs require consideration of what competencies need
to be assessed, how to best assess them, and the level of the
trainee being assessed. Consequently, a three-dimensional
framework for structuring an assessment system can help
medical educators make better judgments about learner
development. Along the first dimension are the competen-
cies that need to be assessed, along the second is the level of
assessment required, and along the third is the trainees’ stage
of development.
Dimension 1: Competencies
As shown in Table 1.1, there are several schemes for describ-
ing the knowledge, skills, and attributes of the physi-
cian.16–19 The CanMEDS model, which was developed and
recently updated by the Royal College of Physicians and
Surgeons in Canada, describes the competencies in terms
of the roles of a physician. Good Medical Practice, which
was created by the General Medical Council in the United
Kingdom, describes the elements of good practice. In the
ACGME/ABMS IOM
Medical knowledge Employ evidence-based practice
Interpersonal and communication skills Work in interdisciplinary teams
Patient care Provide patient-centered care
Professionalism —
Systems-based practice
Practice-based learning and improvement Apply quality improvement
Systems-based practice Utilize informatics
— —
6 CHA P T ER 1 Assessment Challenges in the Era of Outcomes-Based Education
United States, two influential groups developed a set of
core competencies. The Accreditation Council for Gradu-
ate Medical Education (ACGME) and the American Board
of Medical Specialties (ABMS) adopted six general compe-
tencies in 2001. These competencies consist of the educa-
tional outcomes framework for residency and fellowship
training, as well as maintenance of certification programs
throughout a physician’s career in the United States. The
Institute of Medicine (IOM) has recommended five core
skills, or competencies, that create a framework for evaluat-
ing performance and stimulating the reform of education.
They are intended to improve professional education and
practice with a goal of enhancing the safety and quality of
health care. Although there are some differences among the
schemes, there is also significant overlap in these descrip-
tions of a physician.
These competencies are intended as the first step in iden-
tifying key educational outcomes that should inform the
learning objectives, assessment, and curriculum of graduate
training programs, adapted to the content, education, and
practice of the particular specialty/subspecialty. As we will
see later, milestones and entrustable professional activities
(EPAs) are concepts, specified and adapted by specialties,
that can facilitate the implementation of competency-based
programs. The data produced by the assessment of these
competencies serve as a basis for judging the quality of the
trainees and their training, as well as supporting the con-
tinuous improvement of both.
Dimension 2: Levels of Assessment
The multifaceted nature of the competencies makes it appar-
ent that no single method could provide a sufficient basis for
making judgments about students or residents. In an orga-
nized approach to this problem, Miller proposed a classifi-
cation scheme that stratifies assessment methods based on
what they require of the trainee. Often referred to as Miller’s
pyramid, it is composed of four levels: knows, knows how,
shows how, and does.63
Miller’s Pyramid
Knows. This is the lowest level of the pyramid and it con-
tains methods that assess what a trainee “knows” in an area
of competence. Forming the base of the pyramid, knowl-
edge represents the foundation upon which clinical com-
petence is built. An MCQ-based examination composed of
questions focused on ethics and principles of patient con-
fidentiality would provide an assessment of what a trainee
“knows” about professionalism.
Knows how. To function as a physician, a good knowl-
edge base is necessary but insufficient. It is important to
know how to apply this knowledge in the acquisition of
data, the analysis and interpretation of findings, and the
development of management plans. For example, a method
that poses a moral dilemma, asks trainees to reason through
it, and evaluates the sophistication of their moral thinking
would provide a “knows how” assessment of professionalism.
Shows how. Although trainees may know and know
how, they may not be able to integrate these skills into a
successful performance with patients. Consequently, certain
assessment methods require the trainee to show how they
perform with patients. For example, a standardized patient
presenting with an ethical challenge would offer the trainee
an opportunity to “show how” he or she would respond to a
professionalism challenge.
Does. No matter how good traditional assessment meth-
ods become, there remains the concern that what happens
in a controlled testing environment does not generalize
directly or predict what happens in practice. The highest
level of Miller’s pyramid therefore focuses on methods that
provide an assessment of routine performance. For example,
the development and use of a critical incident system, such
as the one currently used in some medical schools, offers
an assessment of what students actually do in terms of
professionalism.
Miller’s pyramid is a useful framework for considering
differences and similarities among assessment methods.
However, the fact that it is a pyramid might imply to some
that methods addressing the higher levels are better, or con-
versely that the larger area occupied by the base of the pyra-
mid implies that knowledge assessment is most important.
Instead, superior methods are those best aligned with the
purpose of the assessment. For example, if an assessment
of foundational medical knowledge is needed, a method
associated with that level (e.g., multiple-choice questions)
is likely better than a method associated with another level
(e.g., standardized patients). Recently Cruess and colleagues
argued to add “Is” to the top of the pyramid to recognize the
importance of professional formation, but it is not yet clear
where this fits into an assessment program.64
The Cambridge Model
As physicians near the end of training and enter practice,
external forces come to play a very large role in performance.
The Cambridge Model, a variation on Miller’s pyramid,
proposes that performance in practice (the highest level
of the pyramid) is influenced by two large forces beyond
competence.65 Systems-related factors, such as government
programs, clinical microsystems (i.e., the clinical units
where learners care for patients), institutional care delivery
practices, patient expectations, and guidelines, among other
factors, strongly influence what physicians do. Similarly,
factors related to the individual physician such as state of
mind, physical and mental health, and relationships with
peers and family have a significant effect. Consequently,
assessment becomes more difficult because it is harder to
disentangle the effects of the context (e.g., context speci-
ficity; see Chapter 7) of care from the competence of the
individual physician. Here, a focus on health care processes
and outcomes as a measure of what a physician “does” can
provide a robust assessment of a physician’s ability to inte-
grate multiple competencies within a complex social con-
text. However, processes and outcomes are still impacted by
system factors that can affect patient preferences and thus
Another random document with
no related content on Scribd:
que en aquella ribera deleitosa
de Nemoroso fue tan celebrada;
porque de todo aquesto y cada cosa
estaba Nise ya tan informada,
que llorando el pastor, mil veces ella 255
se enterneció escuchando su querella.
Y porque aqueste lamentable cuento,
no solo entre las selvas se contase,
mas, dentro de las ondas, sentimiento
con la noticia de esto se mostrase, 260
quiso que de su tela el argumento
la bella ninfa muerta señalase,
y así se publicase de uno en uno
por el húmido reino de Netuno.
Destas historias tales variadas 265
eran las telas de las cuatro hermanas,
las cuales, con colores matizadas
y claras luces de las sombras vanas,
mostraban a los ojos relevadas
las cosas y figuras que eran llanas; 270
tanto que, al parecer, el cuerpo vano
pudiera ser tomado con la mano.[244]
Los rayos ya del sol se trastornaban,[245]
escondiendo su luz, al mundo cara,
tras altos montes, y a la luna daban 275
lugar para mostrar su blanca cara;
los peces a menudo ya saltaban,
con la cola azotando el agua clara,
cuando las ninfas, la labor dejando,
hacia el agua se fueron paseando. 280
En las templadas ondas ya metidos
tenían los pies, y reclinar querían
los blancos cuerpos, cuando sus oídos
fueron de dos zampoñas que tañían
suave y dulcemente, detenidos; 285
tanto, que sin mudarse las oían,
y al son de las zampoñas escuchaban
dos pastores, a veces, que cantaban.
Más claro cada vez el son se oía
de dos pastores, que venían cantando 290
tras el ganado, que también venía
por aquel verde soto caminando,
y a la majada, ya pasado el día,
recogido llevaban, alegrando
las verdes selvas con el son suave, 295
haciendo su trabajo menos grave.
Tirreno destos dos el uno era,
Alcino el otro, entrambos estimados,
y sobre cuantos pacen la ribera
del Tajo, con sus vacas, enseñados; 300
mancebos de una edad, de una manera
a cantar juntamente aparejados,
y a responder. Aquesto van diciendo,
cantando el uno, el otro respondiendo.

TIRRENO

Flérida, para mí dulce y sabrosa 305

más que la fruta del cercado ajeno,[246]
más blanca que la leche y más hermosa
que el prado por abril, de flores lleno;
si tú respondes pura y amorosa
al verdadero amor de tu Tirreno, 310
a mi majada arribarás, primero
que el cielo nos amuestre su lucero.

ALCINO

Hermosa Filis, siempre yo te sea

amargo al gusto más que la retama,
y de ti despojado yo me vea, 315
cual queda el tronco de su verde rama,
si más que yo el murciélago desea
la escuridad, ni más la luz desama,
por ver ya el fin de un término tamaño
deste día, para mí mayor que un año. 320

TIRRENO

Cual suele acompañada de su bando

aparecer la dulce primavera,
cuando Favonio y Céfiro soplando,[247]
al campo toman su beldad primera,
y van artificiosos esmaltando 325
de rojo, azul y blanco la ribera;
en tal manera a mí, Flérida mía,
viniendo, reverdece mi alegría.

ALCINO

¿Ves el furor del animoso viento,

embravecido en la fragosa sierra, 330
que los antiguos robles ciento a ciento
y los pinos altísimos atierra,
y de tanto destrozo aún no contento,
al espantoso mar mueve la guerra?
Pequeña es esta furia, comparada 335
a la de Filis, con Alcino airada.

TIRRENO

El blanco trigo multiplica y crece,

produce el campo en abundancia tierno
pasto al ganado, el verde monte ofrece
a las fieras salvajes su gobierno; 340
adoquiera que miro me parece
que derrama la copia todo el cuerno;[248]
mas todo se convertirá en abrojos
si dello aparta Flérida sus ojos.

ALCINO

De la esterilidad es oprimido 345

el monte, el campo, el soto y el ganado;
la malicia del aire corrompido
hace morir la hierba mal su grado;[249]
las aves ven su descubierto nido,
que ya de verdes hojas fue cercado; 350
pero si Filis por aquí tornare,
hará reverdecer cuanto mirare.

TIRRENO

El álamo de Alcides escogido

fue siempre, y el laurel del rojo Apolo;
de la hermosa Venus fue tenido 355
en precio y en estima el mirto solo;
el verde sauz de Flérida es querido,
y por suyo entre todos escogiolo;[250]
doquiera que de hoy más sauces se hallen,
el álamo, el laurel y el mirto callen. 360

ALCINO

El fresno por la selva en hermosura

sabemos ya que sobre todos vaya,
y en aspereza y monte de espesura
se aventaja la verde y alta haya;
mas el que la beldad de tu figura 365
dondequiera mirado, Filis, haya,
al fresno y a la haya en su aspereza
confesará que vence tu belleza.—

Esto cantó Tirreno, y esto Alcino

le respondió; y habiendo ya acabado 370
el dulce son, siguieron su camino
con paso un poco más apresurado.
Siendo a las ninfas ya el rumor vecino,
todas juntas se arrojan por el vado,
y de la blanca espuma que movieron 375
las cristalinas hondas se cubrieron.
 ELEGÍA PRIMERA

Aunque este grave caso haya tocado[251]

con tanto sentimiento el alma mía,
que de consuelo estoy necesitado,
con que de su dolor mi fantasía
se descargase un poco, y se acabase 5
de mi continuo llanto la porfía,
quise, pero, probar si me bastase[252]
el ingenio a escribirte algún consuelo,
estando cual estoy, que aprovechase
para que tu reciente desconsuelo 10
la furia mitigase, si las musas
pueden un corazón alzar del suelo
y poner fin a las querellas que usas,
con que de Pindo ya las moradoras
se muestran lastimadas y confusas; 15
que, según he sabido, ni a las horas
que el sol se muestra ni en el mar se esconde,
de tu lloroso estado no mejoras;
antes en él permaneciendo, donde
quiera que estás tus ojos siempre bañas, 20
y el llanto a tu dolor así responde,
que temo ver deshechas tus entrañas
en lágrimas, como al lluvioso viento
se derrite la nieve en las montañas.
Si acaso el trabajado pensamiento 25
en el común reposo se adormece,
por tornar al dolor con nuevo aliento,
en aquel breve sueño te aparece
la imagen amarilla del hermano,
que de la dulce vida desfallece; 30
y tú, tendiendo la piadosa mano,
probando a levantar el cuerpo amado,
levantas solamente el aire vano;
y del dolor el sueño desterrado
con ansia vas buscando, el que partido 35
era ya con el sueño y alongado.
Así desfalleciendo en tu sentido,
como fuera de ti, por la ribera
de Trápana con llanto y con gemido
el caro hermano buscas, que sola era 40
la mitad de tu alma, el cual muriendo,
no quedará ya tu alma entera.[253]
Y no de otra manera repitiendo
vas el amado nombre, en desusada
figura a todas partes revolviendo, 45
que cerca del Erídano aquejada,[254]
lloró y llamó Lampecie el nombre en vano,[255]
con la fraterna muerte lastimada:
«Ondas, tornadme ya mi dulce hermano
Faetón; si no, aquí veréis mi muerte, 50
regando con mis ojos este llano.»
¡Oh cuántas veces, con el dolor fuerte
avivadas las fuerzas, renovaba
las quejas de su cruda y dura suerte!
¡Y cuántas otras, cuando se acababa 55
aquel furor, en la ribera umbrosa,
muerta, cansada, el cuerpo reclinaba!
Bien te confieso que si alguna cosa
entre la humana puede y mortal gente
entristecer un alma generosa, 60
con gran razón podrá ser la presente,
pues te ha privado de un tan dulce amigo,
no solamente hermano, un acidente;
el cual, no solo siempre fue testigo
de tus consejos y íntimos secretos, 65
mas de cuanto lo fuiste tú contigo.
En él se reclinaban tus discretos
y honestos pareceres, y hacían
conformes al asiento sus efetos.
En él ya se mostraban y leían 70
tus gracias y virtudes una a una,
y con hermosa luz resplandecían,
como en luciente de cristal coluna,[256]
que no encubre de cuanto se avecina
a su viva pureza cosa alguna. 75
¡Oh, miserables hados! ¡Oh, mesquina
suerte la del estado humano, y dura,
do por tantos trabajos se camina!
Y agora muy mayor la desventura
de aquesta nuestra edad, cuyo progreso 80
muda de un mal en otro su figura.
¿A quién ya de nosotros el eceso
de guerras, de peligros y destierro
no toca, y no ha cansado el gran proceso?
¿Quién no vio desparcir su sangre al hierro 85
del enemigo? ¿Quién no vio su vida
perder mil veces y escapar por yerro?
¿De cuántos queda y quedará perdida
la casa y la mujer y la memoria,
y de otros la hacienda despendida? 90
¿Qué se saca de aquesto? ¿Alguna gloria?
¿Algunos premios o agradecimientos?
Sabralo quien leyere nuestra historia.
Verase allí que como polvo al viento,
así se deshará nuestra fatiga 95
ante quien se endereza nuestro intento.
No contenta con esto la enemiga
del humano linaje, que invidiosa
coge sin tiempo el grano de la espiga,
nos ha querido ser tan rigurosa, 100
que ni a tu juventud, don Bernaldino,
ni ha sido a nuestra pérdida piadosa.
 ¿Quién pudiera de tal ser adivino?
¿A quién no le engañara la esperanza,
viéndote caminar por tal camino? 105
¿Quién no se prometiera en abastanza[257]
seguridad entera de tus años,
sin temer de natura tal mudanza?
Nunca los tuyos, mas los propios daños,
dolernos deben; que la muerte amarga 110
nos muestra claros ya mil desengaños:
hanos mostrado ya que en vida larga
apenas de tormentos y de enojos
llevar podemos la pesada carga;
hanos mostrado en ti que claros ojos 115
y juventud y gracia y hermosura,[258]
son también, cuando quiere, sus despojos.
Mas no puede hacer que tu figura,
después de ser de vida ya privada,
no muestre el artificio de natura. 120
Bien es verdad que no está acompañada
de la color de rosa que solía
con la blanca azucena ser mesclada;
porque el calor templado que encendía
la blanca nieve de tu rostro puro, 125
robado ya la muerte te lo había.
En todo lo demás, como en seguro
y reposado sueño descansabas,
indicio dando del vivir futuro.[259]
Mas ¿qué hará la madre que tú amabas, 130
de quien perdidamente eras amado,
a quien la vida con la tuya dabas?
Aquí se me figura que ha llegado
de su lamento el son, que con su fuerza
rompe el aire vecino y apartado; 135
tras el cual a venir también se esfuerza
el de las cuatro hermanas, que teniendo
va con el de la madre viva fuerza.
A todas las contemplo desparciendo
de su cabello luengo el fino oro, 140
al cual ultraje y daño están haciendo.
El viejo Tormes con el blanco coro
de sus hermosas ninfas seca el río,
y humedece la tierra con su lloro.
No recostado en urna al dulce frío[260] 145
de su caverna umbrosa, mas tendido
por el arena en el ardiente estío,
con ronco son de llanto y de gemido,
los cabellos y barbas mal paradas
se despedaza, y el sutil vestido. 150
En torno dél sus ninfas, desmayadas,
llorando en tierra están sin ornamento,
con las cabezas de oro despeinadas.
Cese ya del dolor, el sentimiento,
hermosas moradoras del undoso 155
Tormes; tened más provechoso intento;
consolad a la madre, que el piadoso
dolor la tiene puesta en tal estado,
que es menester socorro presuroso.
Presto será que el cuerpo, sepultado 160
en un perpetuo mármol, de las ondas
podrá de vuestro Tormes ser bañado.
Y tú, hermoso coro, allá en las hondas
aguas metido, podrá ser que al llanto
de mi dolor te muevas y respondas. 165
Vos, altos promontorios, entre tanto
con toda la Trinacria entristecida[261]
buscad alivio en desconsuelo tanto.
Sátiros, faunos, ninfas, cuya vida[262]
sin enojos se pasa, moradores 170
de la parte repuesta y escondida,
con luenga esperiencia sabidores,
buscad para consuelo de Fernando
hierbas de propriedad oculta y flores;
así en el escondido bosque, cuando 175
ardiendo en vivo y agradable fuego
las fugitivas ninfas vais buscando,
ellas se inclinen al piadoso ruego,
y en recíproco lazo estén ligadas,
sin esquivar el amoroso juego. 180
Tú, gran Fernando, que entre tus pasadas
y tus presentes obras resplandeces,
y a mayor fama están por ti obligadas,
contempla dónde estás; que si falleces
al nombre que has ganado entre la gente, 185
de tu virtud en algo te enflaqueces.
Porque al fuerte varón no se consiente
no resistir los casos de fortuna
con firme rostro y corazón valiente.
Y no tan solamente esta importuna, 190
con proceso cruel y riguroso,
con revolver de sol, de cielo y luna
mover no debe un pecho generoso,
ni entristecello con funesto vuelo,
turbando con molestia su reposo; 195
mas si toda la máquina del cielo
con espantable son y con ruído,
hecha pedazos, se viniere al suelo,
debe ser aterrado y oprimido
del grave peso y de la gran ruína, 200
primero que espantado y comovido.
Por estas asperezas se camina
de la inmortalidad al alto asiento,
do nunca arriba quien de aquí declina.
En fin, Señor, tornando al movimiento 205
de la humana natura, bien permito
a nuestra flaca parte un sentimiento;
mas el eceso en esto vedo y quito,
si alguna cosa puedo, que parece
que quiere proceder en infinito. 210
A lo menos el tiempo que, descrece
y muda de las cosas el estado,
debe bastar, si la razón fallece.
 No fue el troyano príncipe llorado[263]
siempre del viejo padre dolorido, 215
ni siempre de la madre lamentado;
antes, después del cuerpo redemido
con lágrimas humildes y con oro,
que fue del fiero Aquiles concedido,
y reprimido el lamentable coro 220
del frigio llanto, dieron fin al vano
y sin provecho sentimiento y lloro.
El tierno pecho, en esta parte humano,
de Venus, ¿qué sintió, su Adonis viendo
de su sangre regar el verde llano?[264] 225
Mas des que vido bien que corrompiendo
con lágrimas sus ojos no hacía
sino en su llanto estarse deshaciendo,
y que tornar llorando no podía
su caro y dulce amigo de la escura 230
y tenebrosa noche al claro día,
los ojos enjugó, y la frente pura
mostró con algo más contentamiento,
dejando con el muerto la tristura;
y luego con gracioso movimiento 235
se fue su paso por el verde suelo,
con su guirnalda usada y su ornamento.
Desordenaba con lacivo vuelo
el viento su cabello, y con su vista
alegraba la tierra, el mar y el cielo. 240
Con discurso y razón que es tan prevista,
con fortaleza y ser que en ti contemplo,
a la flaca tristeza se resista.
Tu ardiente gana de subir al templo
donde la muerte pierde su derecho, 245
te baste, sin mostrarte yo otro ejemplo.
Allí verás cuán poco mal ha hecho
la muerte en la memoria y clara fama
de los famosos hombres que ha deshecho.
Vuelve los ojos donde al fin te llama 250
la suprema esperanza, do perfeta
sube y purgada el alma en pura llama.
¿Piensas que es otro el fuego que en Oeta[265]
de Alcides consumió la mortal parte[266]
cuando voló el espirtu al alta meta? 255
Desta manera aquel por quien reparte
tu corazón sospiros mil al día,
y resuena tu llanto en cada parte,
subió por la difícil y alta vía,
de la carne mortal purgado y puro, 260
en la dulce región del alegría;
do con discurso libre ya y seguro
mira la vanidad de los mortales,
ciegos, errados en el aire escuro;
y viendo y contemplando nuestros males, 265
alégrase de haber alzado el vuelo
a gozar de las horas inmortales.
Pisa el inmenso y cristalino cielo
teniendo puestos de una y otra mano
el claro padre y el sublime abuelo.[267] 270
El uno ve de su proceso humano
sus virtudes estar allí presentes,
que el áspero camino hacen llano;
el otro, que acá hizo entre las gentes
en la vida mortal menor tardanza, 275
sus llagas muestra allá resplandecientes.
Dellas aqueste premio allá se alcanza;
porque del enemigo no conviene
procurar en el cielo otra venganza.
Mira la tierra, el mar que la contiene,[268] 280
todo lo cual por un pequeño punto
a respeto del cielo juzga y tiene.
Puesta la vista en aquel gran trasunto
y espejo, do se muestra lo pasado
con lo futuro y lo presente junto, 285
el tiempo que a tu vida limitado
de allá arriba te está, Fernando, mira,
y allí ve tu lugar ya deputado.
¡Oh bienaventurado! que sin ira,
sin odio, en paz estás, sin amor ciego, 290
con quien acá se muere y se sospira;
y en eterna holganza y en sosiego
vives, y vivirás cuanto encendiere
las almas del divino amor el fuego!
Si el cielo piadoso y largo diere 295
luenga vida a la voz deste mi llanto,
lo cual tú sabes que pretende y quiere,
yo te prometo, amigo, que entre tanto
que el sol al mundo alumbre, y que la escura
noche cubra la tierra con su manto, 300
y en tanto que los peces la hondura
húmida habitarán del mar profundo,
y las fieras del monte la espesura,
se cantará de ti por todo el mundo;
que en cuanto se discurre, nunca visto 305
de tus años jamás otro segundo
será desde el Antártico a Calisto.[269]
 ELEGÍA SEGUNDA

Aquí, Boscán, donde del buen troyano[270]

Anquises con eterno nombre y vida[271]
conserva la ceniza el Mantuano,[272]
debajo de la seña esclarecida
de César Africano nos hallamos,[273] 5
la vencedora gente recogida;
diversos en estudio; que unos vamos
muriendo por coger de la fatiga
el fruto que con el sudor sembramos;
otros, que hacen la virtud amiga 10
y premio de sus obras, y así quieren
que la gente lo piense y que lo diga,
destotros en lo público difieren,
y en lo secreto sabe Dios en cuánto
se contradicen en lo que profieren. 15
Yo voy por medio, porque nunca tanto
quise obligarme a procurar hacienda;
que un poco más que aquellos me levanto.
Ni voy tampoco por la estrecha senda
de los que cierto sé que a la otra vía 20
vuelven de noche, al caminar, la rienda.
Mas, ¿dónde me llevó la pluma mía,
que a sátira me voy mi paso a paso,[274]
y aquesta que os escribo es elegía?
Yo enderezo, señor, en fin, mi paso 25
por donde vos sabéis, que su proceso
siempre ha llevado y lleva Garcilaso;[275]
y así, en mitad de aqueste monte espeso
de las diversidades me sostengo,
no sin dificultad, mas no por eso 30
dejo las musas, antes torno y vengo
dellas al negociar, y variando,
con ellas dulcemente me entretengo.
Así se van las horas engañando,
así del duro afán y grave pena 35
estamos algún hora descansando.
De aquí iremos a ver de la sirena
la patria, que bien muestra haber ya sido[276]
de ocio y de amor antiguamente llena.[277]
Allí mi corazón tuvo su nido 40
un tiempo ya; mas no sé ¡triste! agora
o si estará ocupado o desparcido.[278]
De aquesto un frío temor así a deshora
por mis huesos discurre en tal manera,
que no puedo vivir con él un hora. 45
Si ¡triste! de mi bien estado hubiera
un breve tiempo ausente, yo no niego
que con mayor seguridad viviera.
La breve ausencia hace el mismo juego
en la fragua de amor, que en fragua ardiente 50
el agua moderada hace al fuego;
la cual verás que no tan solamente
no lo suele matar, mas lo refuerza
con ardor más intenso y eminente;
porque un contrario con la poca fuerza 55
de su contrario, por vencer la lucha,
su brazo aviva y su valor esfuerza;
pero si el agua en abundancia mucha
sobre el fuego se esparce y se derrama,
el humo sube al cielo, el son se escucha, 60
y el claro resplandor de viva llama,
en polvo y en ceniza convertido,
apenas queda dél sino la fama.
Así el ausencia larga, que ha esparcido
en abundancia su licor, que amata 65
el fuego que el amor tenía encendido,
de tal suerte lo deja, que lo trata
la mano sin peligro en el momento
que en aparencia y son se desbarata.
Yo solo fuera voy de aqueste cuento; 70
porque el amor me aflige y me atormenta,
y en el ausencia crece el mal que siento;
y pienso yo que la razón consienta
y permita la causa deste efeto,
que a mí solo entre todos se presenta; 75
porque, como del cielo yo sujeto
estaba eternamente y deputado
al amoroso fuego en que me meto,
así para poder ser amatado,
el ausencia sin término infinita 80
debe ser, y sin tiempo limitado;
lo cual no habrá razón que lo permita;
porque, por más y más que ausencia dure,
con la vida se acaba, que es finita.
Mas a mí ¿quién habrá que me asegure 85
que mi mala fortuna con mudanza
y olvido contra mí no se conjure?
Este temor persigue la esperanza
y oprime y enflaquece el gran deseo
con que mis ojos van de su holganza.[279] 90
Con ellos solamente agora veo
este dolor que el corazón me parte,
y con él y comigo aquí peleo.
¡Oh crudo, oh riguroso, oh fiero Marte,
de túnica cubierto de diamante,[280] 95
y endurecido siempre en toda parte!
¿Qué tiene que hacer el tierno amante
con tu dureza y áspero ejercicio
llevado siempre del furor delante?
Ejercitando, por mi mal, tu oficio, 100
soy reducido a términos que muerte
será mi postrimero beneficio.[281]
 Y esta no permitió mi dura suerte
que me sobreviniese peleando,
de hierro traspasado agudo y fuerte,[282] 105
por que me consumiese contemplando
mi amado y dulce fruto en mano ajena,
y el duro posesor de mí burlando.
Mas, ¿dónde me trasporta y enajena
de mi proprio sentido el triste miedo? 110
Aparte de vergüenza y dolor llena,
donde si el mal yo viese, ya no puedo,
según con esperalle estoy perdido,
acrecentar en la miseria un dedo.
Así lo pienso agora, y si él venido 115
fuese en su misma forma y su figura,
tendría el presente por mejor partido,
y agradecería siempre a la ventura
mostrarme de mi mal solo el retrato,
que pintan mi temor y mi tristura. 120
Yo sé qué cosa es esperar un rato
el bien del propio engaño, y solamente
tener con él inteligencia y trato.
Como acontece al mísero doliente,
que del un cabo el cierto amigo y sano 125
le muestra el grave mal de su acidente,
y le amonesta que del cuerpo humano
comience a levantar a mejor parte
el alma suelta con volar liviano;
mas la tierna mujer, de la otra parte, 130
no se puede entregar a desengaño,
y encúbrele del mal la mayor parte;
él, abrazado con su dulce engaño,
vuelve los ojos a la voz piadosa,
y alégrase muriendo con su daño, 135
así los quito yo de toda cosa,
y póngolos en solo el pensamiento
de la esperanza cierta o mentirosa.
En este dulce error muero contento;
porque ver claro y conocer mi estado 140
no puede ya curar el mal que siento;
y acabo como aquel que en un templado
baño metido, sin sentido muere,
las venas dulcemente desatado.[283]
Tú, que en la patria entre quien bien te quiere 145
la deleitosa playa estás mirando,[284]
y oyendo el son del mar que en ella hiere,
y sin impedimento contemplando
la misma a quien tú vas eterna fama,
en tus vivos escritos, procurando; 150
alégrate, que más hermosa llama[285]
que aquella que el troyano encendimiento
pudo causar, el corazón te inflama.
No tienes que temer el movimiento
de la fortuna con soplar contrario, 155
que el puro resplandor serena el viento.
Yo, como conducido mercenario,
voy do fortuna a mi pesar me envía,
si no a morir, que aquesto es voluntario.
Solo sostiene la esperanza mía 160
un tan débil engaño, que de nuevo
es menester hacello cada día;
y si no lo fabrico y lo renuevo,
da consigo en el suelo mi esperanza;
tanto, que en vano a levantalla pruebo. 165
Aqueste premio mi servir alcanza,
que en sola la miseria de mi vida
negó fortuna su común mudanza.
¿Dónde podré huir que sacudida
un rato sea de mí la grave carga 170
que oprime mi cerviz enflaquecida?
Mas ¡ay! que la distancia no descarga
el triste corazón, y el mal, doquiera
que estoy, para alcanzarme el vuelo alarga.
Si donde el sol ardiente reverbera 175
en la arenosa Libia, engendradora
de toda cosa ponzoñosa y fiera;
o adonde es él vencido a cualquiera hora
de la rígida nieve y viento frío,
parte do no se vive ni se mora; 180
si en esta o en aquella el desvarío
o la fortuna me llevase un día,
y allí gastase todo el tiempo mío;
el celoso temor con mano fría
en medio del calor y ardiente arena 185
el triste corazón me apretaría;
y en el rigor del hielo, en la serena
noche, soplando el viento agudo y puro,
que el veloce correr del agua enfrena,
de aqueste vivo fuego en que me apuro 190
y consumirme poco a poco espero,
sé que aun allí no podré estar seguro;
y así, diverso entre contrarios muero.
 EPÍSTOLA

Señor Boscán, quien tanto gusto tiene[286]

de daros cuenta de los pensamientos
hasta en las cosas que no tienen nombre,
no le podrá con vos faltar materia,
ni será menester buscar estilo 5
presto, distinto, de ornamento puro,[287]
tal cual a culta epístola conviene.
Entre muy grandes bienes que consigo
el amistad perfeta nos concede,
es aqueste descuido suelto y puro, 10
lejos de la curiosa pesadumbre;
y así, de aquesta libertad gozando,
digo que vine, cuanto a lo primero,
tan sano como aquel que en doce días
lo que solo veréis ha caminado 15
cuando el fin de la carta os lo mostrare.[288]
Alargo y suelto a su placer la rienda,
mucho más que al caballo, al pensamiento,
y llévame a las veces por camino
tan dulce y agradable, que me hace 20
olvidar el trabajo del pasado.
Otras me lleva por tan duros pasos,
que con la fuerza del afán presente,
también de los pasados se me olvida.
A veces sigo un agradable medio 25
honesto y reposado en que el discurso
del gusto y del ingenio se ejercita.
Iba pensando y discurriendo un día