Selecting Authentic and Feasible Pass/Fail Assessments in Competency-Based Education: A Clinical Teacher's Toolbox

Competency-based education (CBE) has shifted health professions training away from time-based progression and numerical grading toward criterion-referenced, pass/fail judgements of competence. As programmes adopt CBE, educators must design assessments that generate defensible evidence of competence while remaining sustainable at scale. This Clinical Teacher's Toolbox article presents a comparative framework for selecting summative, pass/fail assessments using two complementary lenses: authenticity and feasibility. We examine commonly used classroom-based assessments, including higher order multiple choice questions, oral examinations (vivas), case-based documentation write-ups, chart-stimulated recall, adaptive virtual case platforms, simulation, objective structured clinical exams (OSCEs), uploaded clinical video demonstrations, simulated patient education videos and emerging virtual or augmented reality approaches. We situate these assessments along Miller's Pyramid and domains of competence. Authenticity is conceptualised as a continuum shaped by task design and the extent to which assessments require integration of knowledge, reasoning, and performance aligned with professional practice. Feasibility reflects faculty workload, feedback capacity, calibration demands, scalability and vulnerability to inappropriate use of artificial intelligence. By integrating these lenses, we demonstrate how combining scalable written assessments with selectively deployed higher authenticity modalities can generate meaningful upstream evidence that supports downstream entrustment decisions. This toolbox offers practical guidance for designing repeatable, defensible and sustainable pass/fail assessment within competency-based programmes.