Self-Assessment in the Health Professions: A Reformulation and Research Agenda

Many researchers and educators have identified self-assessment as a vital aspect of professional self-regulation.1,2,3 This rationale has been the expressed motivation for a large number of studies of self-assessment ability in medical education, health professional education, and professions education generally. Unfortunately, the outcome of most studies would seem to cast doubt on the capacity for self-assessment, with the majority of authors concluding that self-assessment is, in fact, quite poor.4 In a recent article, Ward and colleagues suggested that this conclusion must be questioned because the methodologies used to evaluate self-assessment are fraught with methodological weaknesses.4 However, even studies that have attempted to address the weaknesses within the methodological paradigm have produced little evidence for effective self-assessment.5 Thus, the health professional education community is left with a conundrum that can only be resolved by deciding either that the conclusions of the studies are wrong, or that a critical premise underlying the concept of “self-regulation” in the professions is unsupportable. The current paper addresses this conundrum by arguing that there is a problem with the literature on self-assessment, and that this problem is more fundamental than a list of easily correctable methodological flaws. Rather, the roots of the problem in the self-assessment literature involve a failure to effectively conceptualize the nature of self-assessment in the daily practice of health care professionals, and a failure to properly explicate the role of self-assessment in a self-regulating profession. Until such an articulation of self-assessment is elaborated, it is difficult to know even which literatures might be informative in addressing this issue, and impossible to develop programs of research that operationalize the concept of self-assessment ability in a form that can be effectively studied. Thus, we will begin with a brief reflection on the various functions of self-assessment for a practicing health care professional and the manner in which these functions operate. The Purposes of Self-Assessment in Practice Self-assessment has been defined broadly as the involvement of learners in judging whether or not learner-identified standards have been met.6 While attractive due to their concise and encompassing nature, we fear that such simple definitions risk being misleading as they can cause underappreciation of the complexities of the construct. Self-assessment functions both as a mechanism for identifying one’s weaknesses and as a mechanism for identifying one’s strengths. Each of these mechanisms can be considered to have distinct, albeit complementary, functions. As a mechanism for identifying weaknesses or gaps in one’s skills and abilities, self-assessment serves several potential functions. First, in daily practice, the identification of one’s weaknesses allows the professional to self-limit in areas of limited competence. For example, in many circumstances the professional can quickly reject certain plans of action because she recognizes that she is unlikely to be able to complete the component tasks necessary to enact the plan. In other circumstances, a professional might recognize that he is “over his head” in a particular case and decide that it is time to recruit additional resources: to “look this up,” to obtain a consultation, to recruit additional support, or to refer the problem to another individual who is more competent in this domain. Second, in reflecting on one’s practice in general, the ability to identify weaknesses can serve the function of helping the professional set appropriate learning goals. That is, the traditional model of self-regulated continuing professional development presumes that an individual will select ongoing learning activities that fill professional gaps, but this presumes that the professional can effectively self-assess. Thus, in this role, the identification of weakness can help a professional to decide what must be learned. As a corollary to this, effective self-assessment is vital for setting realistic expectations of oneself, to avoid setting oneself up for failure. Thus, the identification of weakness also helps the self-regulating professional to decide what not to try learning, what should be accepted as forever outside one’s scope of competent practice. There is a complementary set of functions served by the ability to accurately self-assess one’s strengths. First, in daily practice, having a clear and accurate sense of one’s strengths allows the professional to act with appropriate confidence. For example, knowing one’s strengths provides the professional with the confidence to move forward on a fitting plan of action without inappropriate hesitation or trepidation. Similarly, it ensures that the individual will choose to persist on an appropriate plan of action in the face of initially negative feedback. The right path is not always smooth even if it is right, and early abandonment of an appropriate plan of action is as costly as selecting an inappropriate plan in the first place. Second, when reflecting on one’s practice in general, an appropriate assessment of one’s strengths ensures that one can set appropriately challenging learning goals, pushing the edges of one’s knowledge rather than choosing professional development courses that merely reiterate what one already knows. At the same time, by knowing one’s strengths, a professional can select learning objectives that are within her grasp, and therefore will be able to enjoy the motivational influence of attaining her goals and experience the satisfaction of a job well done. Together, then, the ability to accurately assess one’s weaknesses and one’s strengths generates a capacity for finding an effective balance both in daily practice and in setting personal learning goals. In daily practice, it generates a balance of confidence and caution, of persistence and flexibility, of experimentation and safety, and of independence and collaboration. In establishing learning goals, it generates a balance of learning enough but not too much, of starting neither too high nor too low, of knowing what to tackle and what to abandon. And in reflecting on accomplishments, it generates a balance of satisfaction and incentive, of self reward without self delusion. In order to fulfill these various functions, it seems that self-assessment must be effectively enacted in three forms: summatively, predictively, and concurrently. Enacting self-assessment summatively, a professional must reflect on completed performances both for the purposes of assessing the specific performance and for the purposes of assessing his abilities generally. When evaluating performance on a particular task, the professional can often assess the overall quality of the completed job as a question that may come in various forms. That is, the individual might ask how good this performance was relative to what she could have done; relative to what her peers might typically do; relative to the best that could have been done (a gold standard); or relative to some minimally acceptable standard. 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