Miller's Pyramid: Origin, Application, Advantages, Disadvantages, and Impact in Forensic Pathology Teaching

Competency-based medical education (CBME) emphasizes demonstrable competencies rather than time-based training. Miller's Pyramid remains an influential framework for conceptualizing clinical competence, but its contemporary application in forensic pathology education has not been comprehensively examined. This review evaluates its educational basis, applications, advantages, limitations, and relevance to forensic pathology teaching.

A narrative review was conducted of literature on Miller's Pyramid, CBME, workplace-based assessment (WPBA), entrustable professional activities (EPAs), milestones, programmatic assessment, and forensic pathology education. Educational and competency-based training approaches from India, the United States, Canada, and other settings were examined.

Miller's Pyramid comprises four levels: Knows, Knows How, Shows How, and Does, representing progressive development from knowledge to independent practice. In forensic pathology, these levels can guide competency development in medico-legal autopsy, injury interpretation, evidence preservation, documentation, communication, and expert testimony. The framework facilitates alignment of learning objectives, teaching strategies, and assessment methods. However, its hierarchical structure may inadequately reflect the dynamic and context-dependent nature of competence and gives limited attention to professional identity, reflective practice, teamwork, and system-related influences. Integration with WPBA, EPAs, milestones, simulation, and programmatic assessment can address these limitations.

Miller's Pyramid remains a valuable framework for competency-based forensic pathology education. Its integration with contemporary assessment approaches can strengthen validity and support context-sensitive, longitudinal, and multimodal evaluation, ultimately promoting competent, accountable, and practice-ready forensic pathologists.