Performance assessment in medical education: where we've been and where we're going.

The assessment of clinical competence is becoming increasingly complex, patient centered, and student driven. Traditionally, clinical evaluation methods consisted primarily of faculty observations, oral examinations, and multiple-choice tests. Increased faculty work load, discontent with traditional methods of clinical skill assessment, and developments in the fields of psychology and education have led to the formation of new modalities, namely performance assessments. The literature pertaining to the performance assessment with standardized patients is reviewed. Based on this literature, several areas for the future direction of performance assessment are proposed, including (a) toward evidence-based locally developed assessments, (b) toward an understanding of educational outcomes and noncognitive assessment factors, and (c) toward more student-driven assessments.