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The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does". The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how" however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Mill