Have we misunderstood Miller? A re-examination of the pyramid of clinical competence

Miller’s pyramid has profoundly influenced medical education by providing a framework for assessment of clinical competence through four levels: knows, knows how, shows how, does. However, its visual representation has led to interpretations Miller did not intend. This article describes five such interpretations: ( a ) a hierarchical progression of competence, ( b ) the idea that lower levels are left behind as one progresses, ( c ) mapping assessment methods to levels, ( d ) quantifying the compartments, and ( e ) equating ‘does’ with competence. An alternative interpretation is proposed: knowledge is foundational to practice, and the peak represents less observability (not absence) of underlying cognitive processes at the time of clinical action. This has implications for assessment— emphasising integration of knowledge and skills, appropriate sampling across methods and contexts, and the role of professional judgement. Revisiting Miller’s original work may help educators use the framework more thoughtfully in contemporary competency-based medical education.