Residents and Fellows' Guide to Clinical Competence

Assessments of candidates for the certifying exam — to determine if they have attained satisfactory clinical competence and exhibit high standards of professional behavior — are an integral part of the certification process because program directors and your clinical competency committee can evaluate skills that cannot be assessed through a written exam.

This page describes how the ABP defines clinical competence, as well as the important responsibilities your program director and faculty have in evaluating your clinical competence as you progress through your training. In addition, you are responsible for self-evaluation during training and for assuring that educational experiences meet your learning needs.

The ABP defines clinical competency based on the the six core competencies that were adopted by the Accreditation Council for the Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) in 1999 and are currently used by ACGME Review Committees to develop program requirements and evaluate trainees.

The outcome of the integration of the preceding component skills is the ability to manage patients. Excellent medical care results from:

  • The ability to apply knowledge in the clinical setting through evidence-based practice;
  • Effective and efficient use of laboratory tests, diagnostic procedures, and therapeutic modalities;
  • Coordination of care by consultants and non-physician providers of service;
  • Advocacy — putting the patient's best interests first; 
  • Continuous professional development; and
  • Practice improvement.

How Are the Competencies Evaluated?

Assessments of your performance as you progress through training are based on numerous observations by teaching faculty and other members of the health care team and on other evaluative methods during each of the required years of training. Some skills, such as cognitive knowledge, may be assessed through objective measurement such as a well-designed written exam or the ABP In-Training Examination (ITE). Other components, such as certain clinical and procedural skills, are best evaluated by the direct observation and judgment of supervisors and others. Teaching faculty, chief residents, senior residents, nurses, clerks, and other clinical staff can contribute timely and important information regarding your clinical competence and performance. They may be particularly helpful in evaluating the organization of your work, professional attitudes toward colleagues, communication skills, and humanistic care of patients. These are referred to as "360 global rating" evaluations.

Similarly, information regarding effectiveness and quality of patient care may be sought from parents and patients through survey questionnaires. These surveys can support the assessment of clinical judgment, humanistic qualities, professional attitudes and behavior, and moral and ethical behavior, which must rely on numerous observations over time by many — including peers, health care coworkers, parents, and patients. These skills are where residents in general typically experience the majority of serious problems, and strategies to correct problems in these areas are difficult to develop.

The ABP and other organizations, through the milestones project, have developed detailed descriptions of observable behaviors to be used in assessing your expected progression in all of the six competency areas. As individuals progress from medical student to resident to practicing pediatrician, the milestones support the assessment of your readiness to practice medicine without supervision. Your progress through these developmental milestones will be assessed in a variety of ways throughout your training.

Competence in Clinical Settings

The clinical setting is an ideal place to evaluate your ability to provide family-centered care. Observation and documentation of your clinical skills on rounds, at the bedside, and in outpatient encounters will be done on a regular basis by attending physicians and senior residents. Your ability to make decisions in emergency situations will be critiqued in the emergency department, in critical care units, and in other settings. Evaluation by subspecialists during elective rotations will provide similar information.

In general, the role of these teachers and supervisors is to:

  • Confirm and augment key historical facts and physical findings elicited by you;
  • Assess and critique your understanding of case presentations and discussions; and
  • Evaluate and substantiate your decision making, clinical reasoning, cost awareness, risk avoidance, diagnostic abilities, technical proficiency, and, when appropriate, skills in management and leadership of the medical team.

Interpersonal and communication skills, humanistic characteristics, and professional attitudes and behaviors are critical components of providing effective clinical care and are also ideally evaluated in the clinical setting in the actual process of caring for patients.

Procedural Skills

Your performance of certain technical procedures should be observed, evaluated, and documented by qualified physicians. Successful mastery of these skills includes an understanding of their indications, contraindications, and complications, and the ability to interpret their results. The ability to obtain informed consent and to ensure appropriate pain management is essential.

The ACGME Review Committee (RC) for Pediatrics delineates the specific procedures in which residents must demonstrate competence. Documentation of the competence of each resident for each procedure must be maintained by the program in the residents' files.

The ACGME has requirements for procedures considered essential for the area of practice. The ABP does not prescribe the number of times a procedure must be done to ensure competency. It recognizes that manual dexterity and confidence will be different for each resident.

While it should be your responsibility to maintain records of procedures, the program director or a designee should monitor this activity carefully. Varying methodologies have been developed so that individual procedures can be logged and summaries of completed procedures can be accessed when needed to facilitate your evaluations.


Your acquisition of medical knowledge will be assessed on a day-to-day basis by faculty members and other residents as you participate in rounds and clinical discussions. You will also have opportunities to demonstrate your clinical knowledge as a participant or presenter in conferences and small group sessions and through self-directed learning activities. Your knowledge will be objectively tested through the administration of the ABP ITE, which is given annually to residents at all levels of training throughout the country. Objective structured clinical exam (OSCE), or oral exam, may also be used to assess your knowledge.


Professionalism may be assessed by the teaching faculty with input from nurses, peers, supervisory residents, patients, families, and staff members with whom you interact. These evaluations must address all aspects of professionalism as described below.

Physicians must demonstrate responsibility to patients, colleagues, and society. Professionalism includes a commitment to effectively carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. To provide excellent care, physicians must have the welfare of their patients and parents as their primary professional concern. You must convey respect for patients' and families' values and demonstrate integrity, compassion, and sensitivity to patients' and parents' perception of illness and health. Professionalism also includes respect for confidentiality of patient information.

Developing and maintaining your own clinical competence are important components of professionalism. This includes commitment to acquiring and maintaining the knowledge and skill needed to provide excellent care to patients, as well as development of effective communication with patients and colleagues. Collaboration and cooperation with all members of a health care team, including those representing other professions, are essential to achieving optimal patient outcomes, and they are your professional responsibility.

Professional commitment to society includes demonstration of an understanding of the importance of enhancing access to medical care for all families, as well as commitment to continued evaluation and improvement of the quality of care being provided, and to the just distribution of finite health care resources.

The ABP has developed a resource guide for program directors to assist in teaching and assessing professionalism. An annotated bibliography of bioethics references applicable to the care of pediatric patients is also available.

Additional Evaluation Methods

Rounds and conferences provide important opportunities for the program director, teaching faculty, and chief residents to review your participation in and contribution to discussions. Competencies such as clinical judgment, presentation of the patient history, effective use of medical resources, and commitment to scholarship may be evaluated effectively in these settings.

In recent years many training programs have developed additional methods to evaluate various components of a physician's competency. These methods might include standardized or simulated patients, videotaped patient encounters, OSCE, computer-based simulations, mock "codes," self-assessment instruments, and case logs. It is up to the discretion of your program director to determine which methods to use.


How Will I Know How I Am Doing?

The RC requires that all pediatric training programs maintain written and electronic documentation of resident performance and provide formal evaluation and feedback at least twice a year to each resident regarding their performance and progress in the program. The ABP strongly supports the concept of carefully written and electronic documentation of the performance and progress of residents. Both verbal feedback and written evaluations are vital to your education and continuing professional growth.

How Does the ABP Follow My Progress?

As part of the ABP tracking and evaluation program, your program director is asked to indicate annually whether your performance is satisfactory, marginal, or unsatisfactory in clinical competence and satisfactory or unsatisfactory in professionalism. Click or tap the button below to learn what happens if you receive a marginal or unsatisfactory rating or if you transfer to a new program.