High-stakes Examinations Research Articles

Can a low emission zone improve academic performance? Evidence from a natural experiment in the city of Madrid

In the last decades, various policies have been implemented to reduce air pollution exposure and improve public health outcomes. Among these, low emission zones (LEZs) have been shown to effectively enhance air quality and health outcomes. However, their potential positive externalities on other outcomes, such as academic performance, remain largely unexplored. This study examines the LEZ introduced in the city of Madrid in late 2018 and investigates its impact on the academic performance of students schooled in the designated area. Using a difference-in-differences design, we demonstrate the policy’s effectiveness in improving air quality during its first 4 years. Subsequently, we find a significant increase of 0.20 standard deviations in the average EvAU scores (a high-stakes examination for university admission) among high schools located within the LEZ, a critical advantage for students seeking entry into the most competitive university programmes. Notably, our findings reveal positive spillover effects in the surroundings of the LEZ area and a greater improvement with longer and earlier exposure to cleaner air. Overall, this study offers compelling evidence of the educational benefits resulting from the implementation of a low emission zone that successfully improves air quality.

Impact and copying mechanisms towards retakes: A case study of five health training institutions in Sub Saharan Africa.

Academic examination retakes are significant challenges in health professions education. With rigorous clinical assessments and high-stakes examinations, many students struggle to meet academic requirements, resulting in retakes. The voices and experiences of such students have often been absent within the broader discussion of health professions education. This study aimed to assess the impact and copying mechanisms of medical and nursing students with retakes across five Sub-Saharan African universities. Methods This was a mixed-methods explanatory sequential study, integrating quantitative surveys and qualitative interviews. The study involved 764 medical and nursing clinical students from five universities across Sub Saharan Africa: Busitema University (Uganda), Mzuzu University (Malawi), University of Ibadan (Nigeria), Kwame Nkrumah University of Science and Technology (Ghana), and the University of Zambia. Quantitative data were analyzed using descriptive statistics. Qualitative data were explored through thematic analysis based on in-depth interviews with 15 purposively selected students who had experienced retakes. Results Overall, the proportion of students who had ever had a retake in clinical assessments was 12.6%. Thematic analysis revealed emotional and psychological challenges, such as shock, anxiety, fear and suicidal thoughts particularly due to insufficient institutional support and lack of feedback. Many students also reported a perceived sense of unfairness in their assessments. Conclusions The study highlights the multifaceted nature of retakes in health professions education in Sub-Saharan Africa. Recommendations for improvement include providing detailed feedback, transparency in assessments, and enhancing both academic and psychological support systems for students, particularly those at higher risk, such as older students and males. Further research is needed to investigate long-term academic and career outcomes and effective remediation strategies for students experiencing retakes.

‘If you have a question that doesn’t work, then it’s clearly going to upset candidates’: what gives rise to errors in examination papers?

ABSTRACT This study investigated an under-researched source of measurement error in high-stakes examinations, namely mistakes in examination papers (e.g. multiple-choice questions containing more than one correct answer). Such mistakes (henceforth errors) are important, as they can undermine students’ performance in the examination, while also eroding public confidence in the examination system. In light of this, this study sought to understand what gives rise to such errors. To this end, it drew upon in-depth interviews with 36 assessment professionals with knowledge and experience of the examination paper construction process. Through illuminating the demands of the paper construction process and the characteristics of the people who are involved in it, this investigation identified a number of ‘active’ and ‘latent’ human failures that can lead to errors in examination papers. The article argues that, to minimise the risk of error in examination papers, efforts to ‘adapt’ people to the demands of the paper construction process should be carefully combined with efforts to adapt the paper construction process to people requirements. Apart from contributing new knowledge to the field, the study’s findings have also practical implications: examination providers can use them to optimise their paper construction processes to enhance the quality of their assessment instruments.

The Effects of Eliminating Idiomatic American English From High-Stakes Nursing Examinations.

In the United States, English for Speakers of Other Languages (ESOL) health care providers are important to the nursing workforce but often face challenges when taking the NCLEX-RN examination. This study evaluated the effects of removing slang and words with multiple meanings from high-stakes examination questions. This study used a quantitative, experimental posttest-only control group design and included a convenience sample of 169 nursing students from a college in southern Florida. Nursing students performed significantly better on the experimental (M = 79.9 [7.48]) than on the control examination (M = 75.08 [10.51]), t(151.8) = 2.973, p = .003. Students with low language acculturation scores achieved significantly higher scores on the experimental (M = 81.48 [SD = 6.05]) versus the control examinations (M = 72.21 [10.09]), t(60.9) = 4.975, p = .001. Modifying examination questions linguistically can help ESOL nursing students perform better and aid examination creators to design bias-free tests. [J Nurs Educ. 2024;63(12):818-825.].

Motivation and socialization during summer predict medical students’ success: An artificial intelligence study

Purpose The latest reform of French medical studies has moved the National Ranking Examination before residency to the beginning of the sixth-year for undergraduate medical students, thus placing unprecedented workload during the preceding summer. The main objective was to determine whether study conditions and psychosocial factors were associated with student success in this model of intense workload. Materials and Methods An online survey designed with six student-partners was sent at a French Medical School after the examination in 2023. The primary outcome was student success in achieving their main goal (Ranking, Knowledge, Well-being). A machine-learning model (eXtreme Gradient Boosting) was developed and explained using Artificial Intelligence. An AI-guided multivariate logistic regression was performed, Odd Ratios were calculated. Results Out of 123 responses, 75 (61%) of the students achieved their main goal. Motivation and socialization during the summer were the two most important variables for predicting student success. In guided multivariate logistic regression, summer motivation (Odd Ratio = 4.12, 95%CI[1.75–10.30]), summer loneliness (Odd Ratio = 0.35, 95%CI[0.14–0.86]), and student’s main goal (Ranking, Odd Ratio = 2.94, 95%CI[1.15–7.79]) were associated with student success. Conclusions Motivation and socialization during the summer preceding high-stakes examinations are strongly predictive of undergraduate medical students’ success. This study highlights the importance of well-being during summer for student success. Practice points Psychosocial factors during summer are associated with the success of undergraduate medical students during high-stakes examinations. Motivation and socialization are strongly predictive of the student’s success. The effect of motivation and socialization on student’s success are moderated by the Medical School site and the student’s main goal.

Development of a dynamic clinical assessment for finals

Different dental schools assess ‘finals' in different ways. Assessment of applied clinical knowledge and skills are commonly based on either objective structured clinical examinations or multiple ‘long cases'. While iterative changes naturally occur throughout education and assessment, it is important to step back and question what skills should be assessed and either identify or develop new assessment methods. At the point of graduation, these should capture the professional attributes expected of a ‘qualified dentist'. New graduate attributes we consider valuable, which can often be challenging to assess summatively in a high-stakes examination, include effective communication skills in a variety of contexts, the ability to be reactive and responsive, and to manage case complexity appropriately for the graduate level.Here, we report a dynamic assessment incorporating candidate interaction with a range of stakeholders. To reflect progression of changing clinical situations, we move away from solely traditional case-based discussions, which principally assess interaction with an examiner, and have introduced multiple scenarios with rapid situation changes, long-term follow-up, treatment complications and challenging communications. A cross-cutting assessment rubric was developed to assess candidates' information gathering/giving, communication, clinical and diagnostic reasoning, applied knowledge, management and professionalism.

Factors associated with retakes in health Professions Courses: A case study of Five selected Universities in Sub-Saharan Africa.

Academic examination retakes are significant challenges in health professions education. With rigorous clinical assessments, limited training resources and high-stakes examinations, students struggle to meet academic requirements which cab result in retakes. This study aimed to assess the proportion of medical and nursing students with retakes across five Sub-Saharan African universities and to explore factors contributing to the retakes. This was a cross-sectional quantitative study. The study involved 764 medical and nursing clinical students from five universities across Sub Saharan Africa: Busitema University (Uganda), Mzuzu University (Malawi), University of Ibadan (Nigeria), Kwame Nkrumah University of Science and Technology (Ghana), and the University of Zambia. Data was analyzed using descriptive statistics and logistic regression to identify factors associated with retakes. Overall, the proportion of students who had ever had a retake in clinical assessments was 12.6%. Factors associated with retakes are age with students aged 25 and above showed a higher likelihood of failing compared to their younger counterparts (OR: 2.45, 95% CI: 1.06-5.64, P = 0.036) and gender with Male students more likely to get retakes compared to their female counterparts (OR: 1.91, 95% CI: 1.21-3.00, P = 0.005) at univariate, although this association was not statistically significant in multivariate analysis. OSCE was the most frequent examination format associated with retakes, accounting for 47.7% (P < 0.001). The present study brings to light the proportion of students who experienced retakes and the factors associated with retakes among health professions students in Sub-Saharan Africa. This highlights the need for institutional interventions targeting at-risk populations: older and male students, and those with assessment problems related to the different modes of assessing clinical skills. Amelioration of these factors through appropriate support systems could minimize the proportion of students having to retake modules and create a more supportive academic environment. Further research might focus on exploring the proportion of students experiencing retakes in each country and thus determine factors that could contribute to high stakes towards retakes for each country so as to develop country specific solution and improved clinical skills assessment.

Evaluating Inter-Rater Reliability: Transitioning to a Single Rater for Marking Modified Essay Questions in Undergraduate Medical Education

Modified Essay Questions (MEQs) are often included in high-stakes examinations to assess higher-order cognitive skills. If the marking guides for MEQs are inadequate, this can lead to inconsistencies in marking. To ensure the reliability of MEQs as a subjective assessment tool, candidates’ responses are typically evaluated by two or more assessors. Previous studies have examined the impact of marker variance. Current study explores the possibility of assigning a single assessor to mark the students' performances in MEQ based on statistically drawn evidence in the clinical phase of the MBBS program at a private medical school in Malaysia. A robust evaluation method was employed to determine whether to continue with two raters or shift to a single-rater scheme for MEQs, using the Discrepancy-Agreement Grading (DAG) System for evaluation. A low standard deviation was observed across all 11 pairs of scores, with insignificant t-statistics (P&gt;0.05) in 2 pairs (18.18%) and significant t-statistics (P&lt;0.05) in 9 pairs (81.81%). The Intraclass Correlation Coefficient (ICC) results were excellent, ranging from .815 to .997, all with P&lt;0.001. Regarding practical effect size (Cohen’s d), 1 pair (9.09%) was categorized as having a strong effect size (&gt;0.8), 7 pairs (63.63%) as having a moderate effect size (0.5-&lt;0.8), and 3 pairs (27.27%) as having a weak effect size (0.2-&lt;0.5). The data analysis suggests that it is feasible to consider marking MEQ items by a single assessor without negatively impacting the reliability of the MEQ as an assessment tool.

A literature review on the effects of failure in the English subject in national grade 12 examinations on Cambodian students

English plays a pivotal role in high-stakes examinations at both national and international contexts. This review article aims to discuss the effects of failure in the English subject in the national grade 12 examinations on Cambodian students. Drawing on secondary sources such as journal articles, conference papers, theses and dissertations, official documents or research reports, books, book chapters, and newspaper articles, the article highlights a number of effects of students’ failure in national high school exams in general contexts, such as (a) increased school dropouts, (b) limited higher education enrolment, (c) limited job opportunities, and (d) compromised psychological well-being. The article also identifies several effects of failure in the English subject in national grade 12 examinations on Cambodian students. These include effects on (a) educational opportunities, (b) job opportunities, (c) communication ability, and (d) psychological well-being. The article provides some recommendations to help students who fail the English subject in the national exam deal with the consequences after exam failure. The recommendations focus on the roles of various stakeholders in general education in Cambodia, such as the Ministry of Education, Youth, and Sport (MoEYS), teachers, parents, students, and other relevant stakeholders. The article concludes with some suggestions for future research.

Minimal change in achievement in high-stakes mathematics examinations in low socio-economic status environments in post-apartheid South Africa

Since various curriculum versions have been implemented in the post-apartheid era, achievement results in high-stakes mathematics examinations are still structured along socio-economic status lines. Continuing professional development (CPD) for mathematics teachers is widely viewed as a mechanism to address this issue. This study uses a specific CPD project to explore the question, “Are three decades-long enough to enhance achievement outcomes in high-stakes mathematics examinations for learners from low socio-economic status environments?” Bricolage is employed as the underlying research framework due to the multifaceted nature of CPD. In one of the residential institutes in 2018, a 7-item questionnaire, based on features of effective CPD and containing four ordinal response categories, was administered to 55 participating teachers (30 females and 25 males). To acknowledge the complex nature of CPD, themes were developed and primarily analysed using descriptive statistics. The analysis revealed that, although mathematics teachers respond favourably to practising previously taught material, there are factors that hinder the sustainability of such an approach. It is concluded that 30 years is not a sufficient timespan to expect significant change. It is recommended that drastic measures be taken regarding the continuing professional development of mathematics teachers to address disparities along class and racial lines.

Ethnic bias and the hidden curriculum: The impact of routine inclusion of ethnicity in medical education assessment

Introduction: In 2012, the University of Otago Medical School in New Zealand amended high stakes examination questions to routinely include ethnicity. This policy change was prompted by the assessment committee, including the Māori subcommittee. This study aimed to examine the portrayal of Māori patients and to explore the impact of routine inclusion of ethnicity. Methods: A quantitative description of demographic variables of examination questions and responses (role-model answers, multiple-response preferred answer, guidelines for markers) from a pre policy (2009–2011), post policy (2012–2013) and follow-up period (2018–2019) was undertaken. A qualitative content analysis of Māori examination questions was conducted with consideration of trends over time. Results: The majority (98%) of examination questions did not report ethnicity prior to the 2012 policy, whereas around 80% of cases did post policy implementation. Three themes were identified: the non-adherent Māori patient, determinants of health and the patient assigned Māori ethnicity. Examination questions and responses that portrayed Māori as being non-adherent were more common prior to the implementation of the policy. Post policy, many questions did not require students to consider the relevance of ethnicity but presented an increase in social and cultural contextual information of the patient over time. Conclusion: Policy implementation by the assessment committee led to less racist stereotyping and “othering” of Māori patients and prompted further refinement of social and cultural determinants of health over time. Future recommendations include increasing representation of Māori as a reflection of the increased burden of disease alongside representing intersectionality using other socio-cultural indicators.

GPT-4o vs. Human Candidates: Performance Analysis in the Polish Final Dentistry Examination.

Background This study aims to evaluate the performance of OpenAI's GPT-4o in the Polish Final Dentistry Examination (LDEK) and compare it with human candidates' results. The LDEK is a standardized test essential for dental graduates in Poland to obtain their professional license. With artificial intelligence (AI) becoming increasingly integrated into medical and dental education, it is important to assess AI's capabilities in such high-stakes examinations. Materials and methods The study was conducted from August 1 to August 15, 2024, using the Spring 2023 LDEK exam. The exam comprised 200 multiple-choice questions, each with one correct answer among five options. Questions spanned various dental disciplines, including Conservative Dentistry with Endodontics, Pediatric Dentistry, Dental Surgery, Prosthetic Dentistry, Periodontology, Orthodontics, Emergency Medicine, Bioethics and Medical Law, Medical Certification, and Public Health. The exam organizers withdrew one question. GPT-4o was tested on these questions without access to the publicly available question bank. The AI model's responses were recorded, and each answer's confidence level was assessed. Correct answers were determined based on the official key provided by the Center for Medical Education (CEM) in Łódź, Poland. Statistical analyses, including Pearson's chi-square test and the Mann-Whitney U test, were performed to evaluate the accuracy and confidence of ChatGPT's answers across different dental fields. Results GPT-4o correctly answered 141 out of 199 valid questions (70.85%) and incorrectly answered 58 (29.15%). The AI performed better in fields like Conservative Dentistry with Endodontics (71.74%) and Prosthetic Dentistry (80%) but showed lower accuracy in Pediatric Dentistry (62.07%) and Orthodontics (52.63%). A statistically significant difference was observed between ChatGPT's performance on clinical case-based questions (36.36% accuracy) and other factual questions (72.87% accuracy), with a p-value of 0.025. Confidence levels also varied significantly between correct and incorrect answers, with a p-value of 0.0208. Conclusions GPT-4o's performance in the LDEK suggests it has potential as a supplementary educational tool in dentistry. However, the AI's limited clinical reasoning abilities, especially in complex scenarios, reveal a substantial gap between AI and human expertise. While ChatGPT demonstrates strong performance in factual recall, it cannot yet match the critical thinking and clinical judgment exhibited by human candidates.

SETTING AND EXAMINATIONS WITH HIGH STAKES IN GENERAL EDUCATION SYSTEMS: A SOCIO-PHILOSOPHICAL ANALYSIS

The article examines the socio-philosophical foundations of the debate about the appropriateness of high-stakes exams and setting in general education systems. The arguments “for” and “against” that are most often used in the discussion are analysed. It is shown that the answer to the question of the appropriateness of high-stakes examinations and setting can be framed as an ethical choice between fairness and efficiency. D. Rawls’s mental argument “the veil of ignorance” and its logical consequences are presented as a possible universal argument in favour of justice. The conclusion emphasises the philosophical nature of key debates about the education policy.

Low-Stakes, Growth-Oriented Testing in Large-Enrollment General Chemistry 1: Formulation, Implementation, and Statistical Analysis.

We formulate an alternative to high-stakes examinations that is designed to help students grow, and we describe its implementation in a large-enrollment General Chemistry 1 class. In our alternative grading approach, students complete weekly assessments. Each assessment has four items that are aligned to explicit learning objectives and a level in Marzano's taxonomy, retrieval, comprehension, analysis, and knowledge utilization, which can be used by students and instructors to gauge the progression of student learning. Proficiency-based grading and multiple attempts reduce the stakes of the assessments. Unique assessments are generated through a computational infrastructure that draws question stems from an item bank and further randomizes quantities, elements, compounds, reactions, spectra, Lewis structures, orbitals, etc. in the questions. Nearly all assessment items require student-generated responses and cover a complete General Chemistry 1 curriculum. We interpret Marzano's taxonomy in the General Chemistry context and outline the structure of the learning objectives, cognitive levels, assessment schedule, and grading scheme. Item response theory (Rasch analysis) validates the theoretical framework and indicates that assessment items are high quality. Students demonstrate improvement through assessment retakes, and they report that the system motivates them to study and learn.

Examining China's “Double Reduction” Policy: Promises and Challenges for Balanced and Quality Development in Compulsory Education

Purpose This study provides an overview of the “double reduction” policy promulgated in 2021, through which the Chinese government attempts to relieve the burden of excessive school homework and off-campus tutoring for students in compulsory education. Design/Approach/Methods This study draws on policy documents and relevant literature to interpret policy origins, core values, and major measures. The positive effects and challenges faced in implementing policies for the balanced and high-quality development of compulsory education were analyzed. Findings Students’ academic burden is deeply rooted in Chinese historical and sociocultural contexts. The “double reduction” policy shows the Chinese government's strong aspiration to promote holistic education for students and pursue the universal provision of balanced, high-quality school education. Despite some positive effects at the implementation level, challenges remain unaddressed. To achieve a policy vision, it calls for a deep reflection on the high-stakes examination system and collective efforts from stakeholders within or outside the education system. Originality/value This study helps elucidate the “double reduction” policy and compulsory education development in China.

ChatGPT as an item calibration tool: Psychometric insights in a high-stakes examination

Introduction:ChatGPT has attracted a lot of interest worldwide for its versatility in a range of natural language tasks, including in the education and evaluation industry. It can automate time- and labor-intensive tasks with clear economic and efficiency gains. Methods: This study evaluated the potential of ChatGPT to automate psychometric analysis of test questions from the 2020 Portuguese National Residency Selection Exam (PNA). ChatGPT was queried 100 times with the 150 MCQ from the exam. Using ChatGPT's responses, difficulty indices were calculated for each question based on the proportion of correct answers. The predicted difficulty levels were compared to the actual difficulty levels of the 2020 exam MCQ’s using methods from classical test theory. Results:ChatGPT's predicted item difficulty indices positively correlated with the actual item difficulties (r (148) = −0.372, p < .001), suggesting a general consistency between the real and the predicted values. There was also a moderate significant negative correlation between the difficulty index predicted by ChatGPT and the number of challenges (r (148) = −0.302, p < .001), highlighting ChatGPT′s potential for identifying less problematic questions. Conclusion: These findings unveiled ChatGPT’s potential as a tool for assessment development, proving its capability to predict the psychometric characteristics of high-stakes test items in automated item calibration without pre-testing in real-life scenarios.

Investigating first instinct fallacy in cytology education and cytomorphology examination

The specific aims of the study are to assess whether answer changing on a high-stakes cytomorphology examination will lower the cytology examinees' scores and to examine whether there is a difference in the frequency of responses changed between high-, average-, and low-performing cytology learners. The paper also seeks to explore if there is a correlation between outcomes of answer changes (success rates) and cytology learner's levels of performance. The eraser marks and pen cross-outs on the cytology final image examinations from 2019-2023 were reviewed and the number of changes made by the examinees and the frequency to which scores were raised or lowered as a result was recorded. Moreover, the response change patterns and outcomes across low-, medium-, and high-performing cytology learners were further analyzed for possible relationships. Among the total number of questions where answer(s) were changed (n = 98), close to half (n = 47, 48.0%) of the changes resulted in raising the score, compared with about one-third (n = 34, 34.7%) that lowered it. When the students were classified into academic abilities, there was a significant correlation between the success rates of answers changed across low-, medium-, and higher-performing learners χ2 (df = 24, n = 24) = 10.24, P < 0.05. Our data also showed the average student group to have the highest "scores raised" to "scores lowered" ratio. Based on these findings, those cytology examinees who are overly cautious about changinginitial responses during a high-stake multiple-choice question BOC test may put themselves at a disadvantage.

Do Exam Aims and Content Reflect those of the Curriculum? An Evaluative Study

Language tests, particularly high-stakes language tests, are a powerful tool for evaluating educational outcomes, but their effectiveness hinges on how they are constructed. Failure to construct valid sound tests can negatively impact both teaching and learning. Therefore, continuous research is needed to investigate and evaluate such types of tests. This study examines the congruency between the aims and content of a high-stakes public EFL examination and the prescribed curriculum in Libyan schools. Document analysis was conducted on a sample of the studied test, focusing on its intended objectives and their reflection on the curriculum's goals and content. While the exam offered some practical advantages, the findings revealed a mismatch between the administered exam and the curriculum, and between the stated aims and the actual content of the exam itself. The assessment focused solely on grammar points and reading comprehension based on information cloned verbatim from the prescribed textbook. Writing was assessed indirectly through true-false responses to prompts involving structured or unstructured sentences. Notably, the exam entirely neglected listening and speaking skills. These findings suggest that the current examination system could hinder curriculum implementation and EFL education in Libyan schools. Therefore, the study calls for examination reform to ensure alignment between the tests and the English curriculum, ultimately promoting effective second language learning.

Overview of the Foreign Language Sections in the Matriculation Exam in Poland and the University Entrance Exam in Türkiye

This paper highlights the contrasting approaches to foreign language assessment in high-stakes examinations for university education in Poland and Türkiye, focusing on content, task types, and language skills. In Poland, language acquisition is seen as a tool for effective communication, while in Türkiye, it is often perceived as rote memorization of grammar and vocabulary. This difference in mindset is influenced by prevailing assessment practices, where Türkiye’s evaluation methods prioritize memorization, leading to a diminished emphasis on communication and practical language use. This disparity is reflected in the EF English Proficiency Index, with Poland ranking high and Türkiye ranking low in language proficiency. Neglected language skills, such as speaking and listening, further exacerbate the issue. Despite discussions on transforming assessment practices for decades, Türkiye has made little progress. The practicality of multiple-choice-based tests in Türkiye is noted, but their limitations in testing language skills comprehensively are acknowledged.

Reimagining Initial Certification as a Process That Begins During Residency to Support Continuous Development Across Training and Practice.

In the United States, initial board certification remains focused on a high-stakes knowledge examination after completion of training. A more contemporary view supports a program of assessment that includes multiple types and sources of data with an emphasis on direct workplace observation to get the best picture of an individual's performance. In this article, the authors reimagine initial certification as a continuous assessment for learning that begins in residency, focuses on both knowledge acquisition and its application, and interdigitates intentionally with the first cycle of maintenance of certification to advance learning and smooth the transition from training to practice. A more expanded view of competence, as a 3-layered construct (canonical, contextual, and personalized), supports this proposal. Canonical competence (context-independent knowledge)-best assessed through examinations of knowledge-is most heavily weighted and assessed during medical school but remains critical throughout one's career. Contextual competence (context-dependent knowledge) is best assessed in the workplace and is key during residency and fellowship as trainees navigate a myriad of clinical work environments. Personalized competence, representing the totality of one's unique areas of expertise, is best demonstrated during the practice years when deliberate practice experience supports the growth of personalized expertise and discoveries that advance the field. Shifting initial board certification from relying on an anxiety-provoking, high-stakes, often single moment in time standardized examination to a nuanced approach that is part of an individual trainee's program of assessment offers a more just and robust decision about readiness for unsupervised practice. Such a model would also sow the seeds of meaningful individualization of learning needs that begins in training, continues through practice, and lays the foundation for improving the quality of care for patients within a given practice as well as shifting the current contiguous phases of training and practice into a true continuum.