Validity in the Era of Competency-Based Health Professions Education: Tensions and Potential Solutions

Assessment in health professions education has evolved dramatically in the past hundred years. The way in which we conceptualize validity has also required evolution, particularly in the era of competency-based health professions education (CBHPE). The CBHPE approach compels us to reexamine a historical focus on objectivity, individual assessments, and standards of achievement alone. In this manuscript, the authors explore the implications CBHPE places on validity, highlighting three tension points: the paradigm of assessment, levels of validation, and the reference for competence. The authors examine health profession education's historical orientation toward the post-positivist paradigm including an emphasis on standardization, reliability, and truth-seeking. This is contrasted with two alternative paradigms, constructivism and pragmatism, which prioritize different data sources to build validity arguments. In the section on levels of validation, the authors explore tensions between validity arguments that are holistic (considers the entire picture of performance) and those which use a decomposition approach (distilling competence into individual components). Finally, the authors consider the value in measuring learner competence using norm-referenced standards, criterion-reference approaches, or the measurement of growth throughout (and beyond) their training. Ultimately, the authors propose a balanced approach to address each tension, considering the strengths and weaknesses of traditional methods with the modern needs of CBHPE.