Creative Education
2013. Vol.4, No.6A, 23-28
Published Online June 2013 in SciRes (http://www.scirp.org/journal/ce) http://dx.doi.org/10.4236/ce.2013.46A005
Investigating the Reliability and Validity of Self and Peer
Assessment to Measure Medical Students’
Professional Competencies
Tyrone Donnon1, Joann McIlwrick2, Wayne Woloschuk2
1Office of Health Medical Education Scholarship, Faculty of Medicine, University of Calgary, Calgary, Canada
2Office of Undergraduate Medical Education, Faculty of Medicine, University of Calgary, Calgary, Canada
Received April 10th, 2013; revised May 12th, 2013; accepted May 20th, 2013
Copyright © 2013 Tyrone Donnon et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
The use of peer assessment through a multisource feedback process has gained recognition as a reliable
and valid method to assess the characteristics of professionals and trainees. A total of 168 first-year
medical students completed a 15-item questionnaire to self-assess their professional work habits and in-
terpersonal abilities. Each student was expected to identify 8 first-year classmates to complete a corre-
sponding 15-item peer assessment. Although the self and peer assessment questionnaires had strong reli-
ability (Cronbach’s α = 0.85 and 0.91, respectively), an exploratory factor analysis resulted in a 3- and 2-
factor solution, respectively. The third factor was associated with items related to students’ personal at-
tributes. Significantly lower mean score differences for the self-report assessment were found for all 15
items (Cohen’s d = 0.27 to 1.39, p < 0.001). A decision study analysis found that 7 peer assessors were
needed to achieve a generalizability coefficient of 0.70. The findings suggest some inconsistencies in re-
gards to the construct validity and stability of measures between self and peer assessment measures. The
need for self-awareness of students’ strengths and limitations, however, is recommended as part of their
development in a profession that emphasizes self-regulation.
Keywords: Self Assessment; Peer Assessment; Multisource Feedback; Medical Students
Introduction
Professionalism is a cornerstone of medical practice, reflect-
ing the qualities we demand of our practitioners and the expec-
tations we have for the medical students we accept into the
profession (Papadakis et al., 2005). Although there are various
approaches that can be used to assess professionalism, the use
of direct observation compiled through a 360 degree evaluation
or multi-source feedback (MSF) format has been recognized as
one of the most effective methods for the assessment of profes-
sionalism (Arnold, 2002; Bandiera et al., 2006; ACGME, 2013).
Although professionalism is a multi-faceted construct that in-
cludes a range of measures from the personal (e.g., ability to
self-reflect and regulate), attitudinal (e.g., altruistic, honesty,
integrity) and behavioral (e.g., dutifulness, collegiality), the use
of MSF has the potential to be used as a formative or summa-
tive feedback process for evaluating specific components of
professionalism. For example, within the context of medical
practice MSF has been shown to be successful in evaluating
physicians’ professional attitudes and behaviors from a range of
stakeholder perspectives that include other physicians, cowork-
ers and the patients’ themselves (Violato & Lockyer, 2006;
Allerup et al., 2007; Brinkman et al., 2007; Lockyer & Clyman,
2008).
The introduction of MSF at the medical school level to as-
sess professional attitudes and behaviours reflects a progressive
move towards acknowledging the importance the profession
places on this role or core set of competencies (Epstein et al.,
2004; ACGME, 2013). There are constrains, however, to in-
troducing a MSF process at medical schools in that as students
the assessment is restricted to other peers as they are the only
other persons that will have observed and know each other well
enough. In addition, the peer assessment is constrained by what
other students can realistically observe and assess about each
other as it relates to the professional attributes displayed
through education activities shared mutually. In particular, the
peer assessment protocol has shown promise as a reliable and
valid method to assess the professional competence of medical
students (Epstein et al., 2004; Dannefer et al., 2005). Used in
part to assess the domains of competence such as interpersonal,
humanistic, and teamwork skills, the 15 item peer assessment
form was shown to distinguish between two domains of stu-
dents’ professional competence: consistency in their work re-
lated habits and interpersonal habits.
The subsequent research on the use of the peer assessment
protocol with undergraduate medical students has expanded to
explore the effects of rater selection (Lurie et al., 2006a),
changes in self-perceived abilities among man and women
(Lurie et al., 2007a), the relationship between peer assessments
and other measures (e.g, Dean’s letter rankings and ratings by
internship directors) (Lurie et al., 2007b), and temporal and

T. DONNON ET AL.
group-related trends (Lurie et al., 2006b). In each case, the
structure of the peer assessment form is premised on the meas-
ure of two identified dimensions referred to as work habits and
interpersonal abilities. In a qualitative study of the impact that
the peer assessment protocol had at the University of Rochester
School of Medicine and Dentistry, medical students reported
that they found the process transformative and a useful source
of feedback that contributed to their own professional devel-
opment (Nofziger et al., 2010).
In this study, we describe the implementation and results of a
formative self and peer assessment protocol as a measure of
medical students’ professional competence in their first and
second years at a medical school in Canada. The responses
were analyzed to determine the reliability (i.e., internal consis-
tency, test-retest, and generalizability coefficients) and con-
struct validity (i.e., factor analysis) of the self and peer ques-
tionnaires and to explore relationships between self and peer
assessment ratings.
Method
Participants
As a component of the student feedback process in the un-
dergraduate medical education program, a total of 168, first
year medical students from the University of Calgary com-
pleted an online 15 item, self assessment form during the mid-
dle of their first year and, then again, at the middle of their
second year. All of the participants were asked to identified 8
classmates to complete a peer assessment version of the ques-
tionnaire in their first year using the same 15 items. This study
was approved by the Conjoint Health Research Ethics Board of
the University of Calgary and signed consent was obtained by
all participants.
Questionnaire
The 15 item Likert form was developed through initial re-
search by Dannefer et al. (2005) on a peer assessment protocol
to measure medical students’ professional competencies as a
function of observable behaviors (Appendix). In particular,
their findings supported a two factor or subscale measure with
high internal reliability (Cronbach’s alpha greater than 0.80 for
each subscale) that assesses students’ professional work habits
(WH) and interpersonal abilities (IA). The 15th item is not con-
sidered to be connected to either factor or subscale and is
treated as an overall assessment of the individual’s potential for
professional competency; reflecting on whether or not the as-
sessor is concerned about this person’s future patients. The
scoring of each item is based on a 5-point scale anchored by
descriptors at each end and the option to circle UA for “unable
to assess”. For example a score of 1 or 2 for item number 13
states that the person’s “behavior is frequently inappropriate” to
options 4 or 5 for “behavior is always appropriate”.
Statistical Analysis
The construct validity of the self and peer assessment ques-
tionnaires were investigated with exploratory factor analysis
using principal components and varimax rotated solutions. The
internal reliability (Cronbach’s alpha), and generalizability
coefficients were calculated in a decision study analysis to de-
termine the optimal number of peer assessors required to obtain
a generalizability coefficient of greater than 0.70 (Brennan,
2001).
A comparison of mean differences between self and peer as-
sessment ratings on each of the 15 items was conducted using
independent samples t-tests with an effect size difference
(Cohen’s d) analysis. The interpretation of the magnitude of the
effect size for mean differences is based on Cohen’s (1988)
suggestions of d of 0.30 as “small”, d of 0.50 as “medium”, and
d of 0.80 as “large”. In addition, for the independent variable
sex (men vs. women) mean differences in the self and peer
assessments were also investigated using independent samples
t-tests and effect size difference analyses.
As there have been found to be discrepancies between self
and peer assessment on other measures of professional compe-
tencies using multisource feedback, medical students’ self as-
sessments were classified into quartile categories (i.e., < 25th
percentile, 26th to 50th percentile, 51st to 75th percentile, and >
76th percentile) based on their mean total scores across all 15
items on the questionnaire and compared with their corre-
sponding peer assessments.
Results
The Cronbach’s alpha coefficients for the self and peer as-
sessments questionnaires were α = 0.85 and 0.91, respectively.
An average of 7.5 peer assessment questionnaires were com-
pleted for each medical student self assessment. On all 15 of the
items shown in Table 1, the mean ratings of the medical stu-
dents on the self assessment questionnaire were significantly
lower than those on the students’ corresponding peer assess-
ment ratings (p < 0.001). Overall, the medical students consis-
tently score themselves lower than their peers with a mean ef-
fect size difference of d = 0.69 across all 15 items (range from
d = 0.27 to 1.39). A large effect size difference (d = 1.17, p <
0.001) was found across a total score comparison between the
self and peer assessment groups.
On the self assessment questionnaire items women (n = 88,
52%) were significantly more likely to report themselves as
having higher “respect, compassion and empathy” [Item #4: M
= 4.64 (SD = 0.50), p < 0.01, d = 0.43], “seeks to understand
others/sensitivity” [Item #5: M = 4.50 (SD = 0.60), p < 0.05, d
= 0.36], “seeks responsibility” [Item #8: M = 4.13 (0.57), p <
0.001, d = 0.53], and “behavior is always appropriate” [Item
#13: M = 4.63 (.49), p < 0.01, d = 0.42] than did men (n = 80,
48%). Peer assessors also rated women significantly higher
than men on three of these four items but the effect size differ-
ences were minimal in comparison: [Item #4: M = 4.73 (SD =
0.52), p < 0.001, d = 0.22], [Item #8: M = 4.60 (.54), p < 0.001,
d = 0.18], and [Item #13: M = 4.79 (0.44), p < 0.001, d = 0.21].
In addition, women were rated significant higher than men by
their peer assessors on being “consistently well prepared” [Item
#1: M = 4.48 (SD = 0.58), p < 0.01, d = 0.16] and that their
“dress and appearance was always appropriate for the situation”
[Item #12: M = 4.83 (SD = 0.44), p < 0.01, d = 0.15]. On Item
#3, however, men students were rated by their peer assessors to
be significantly higher on their ability to “explain clearly their
reasoning process” [M = 4.58 (SD = 0.58), p < 0.01, d = 0.17]
than women.
As shown in Figure 1, when students’ self assessment scores
were compared with their corresponding peer assessments by
quartile groupings, medical students’ in the lowest three quartiles
score themselves significantly l wer that their peer assessors o
24

T. DONNON ET AL.
Table 1.
Means (standard deviations) and effect size differences between items on the self and peer assessment instruments.
Self Assessmenta
(n = 168)
Mean (SD)
Peer Assessment
(n = 1267)
Mean (SD)
Effect size
Difference
Mean (SD)
1) Consistently well prepared
2) Identifies and solves problems
3) Clearly explains reasoning processes
4) Demonstrates respect, compassion
5) Seeks to understand others/sensitivity
6) Takes initiative
7) Shares information with others
8) Seeks responsibility
9) Asks for and implements feedback
10) Trustworthy
11) Admits mistakes
12) Dress and appearance appropriate
13) Behaves appropriately
14) Thinks and works independently
3.55 (0.60)
3.98 (0.48)
4.03 (0.59)
4.52 (0.59)
4.39 (0.62)
3.88 (0.75)
4.25 (0.64)
3.96 (0.65)
3.72 (0.73)
4.40 (0.61)
4.41 (0.61)
4.55 (0.60)
4.52 (0.55)
4.37 (0.66)
4.25 (0.61)
4.42 (0.65)
4.54 (0.57)
4.54 (0.59)
4.68 (0.58)
4.59 (0.60)
4.37 (0.67)
4.52 (0.64)
4.56 (0.59)
4.44 (0.62)
4.74 (0.50)
4.71 (0.52)
4.80 (0.45)
4.74 (0.51)
4.71 (0.50)
4.64 (0.56)
1.39
1.06
0.86
0.27
0.33
0.69
0.42
0.98
1.06
0.61
0.53
0.48
0.42
0.59
0.67
Total Score 62.38 (5.53) 68.97 (5.76) 1.17
Note: aIn independent samples t-tests between Self and Peer Assessment items, p < 0.001.
tend to cross load between factors (items 6, 7, 8, 9, and 10). The
internal reliability coefficients for the peer assessment ques-
tionnaire were α = 0.87 for the WH and α = 0.86 for the IA sub-
scales. For the three factor solution derived for the self assess-
ment questionnaire the internal reliability coefficients were
lower at α = 0.60 (WH), α = 0.80 (IA), and α = 0.77 (PA); re-
flecting in part the reduced number of items associated with
each factor or subscale. The total percentage of the variance ac-
counted for by the self and peer assessment questionnaires were
found to be 53.6% and 57.3%, respectively.
The generalizability (G) coefficient for the peer assessment
with 8 raters for the 15 item checklist was Ep2 = 0.73. A deci-
sion study analysis was used for this single-facet nested design
(i.e., peer assessors nested within individual medical students)
to derive mean G coefficients of 0.58 to 0.80 for 4 to 12 peer
assessors, respectively (Figure 2). The proportion of variance
accounted for by persons (medical students) in the analysis was
25% and the remaining 75% of the variance was contributed
through the peer assessors nested within student interaction
effect.
Figure 1.
Mean percentile on four quartile groups comparing self to peer assess-
ment total scores.
(p < 0.001). In particular, those in the lower self assessment
quartile underestimated their performance competency in com-
parison with their peer assessors by 12.3% of the total score.
There was, however, no significant differences found between
self and peer assessment total means scores in the top 4th quar-
tile. Regardless of the discrepancies found in the self assess-
ment percentile rankings, peer assessments were found to be
not significantly difference and consistent across all quartiles
(67.7% to 69.7%).
A subsequent administration of the 15 item questionnaire
was completed approximately 12 months later in the middle of
the students’ second year. A test-retest reliability analysis re-
sulted in a correlation coefficient of r = 0.44 and an overall
significant increase in students’ total scores from year one (M =
62.5, SD = 5.47) to year two (M = 65.6, SD = 4.54, p < 0.001; d
= 0.62). A subsequent exploratory factor analysis on the com-
pleted self assessment questionnaire for year two also con-
firmed a three factor solution (accounting for 52% of the vari-
ance). In paired sample t-tests between the two administrations,
students were found to rate themselves significantly higher on
each of the three subscales identified: WH (from M =19.9, SD =
1.94 to M = 20.8, SD = 1.75; p < 0.001; d = 0.48), IA (from M
= 17.9, SD = 1.87 to M = 18.4, SD = 1.63; p < 0.01; d = 0.28),
and PA (from M = 20.6, SD = 2.30 to M = 21.8, SD = 1.90; p <
0.001; d = 0.57). In addition, students’ rated themselves signifi-
cantly higher in year two on question 15 regarding the effec-
tiveness of their healthcare practice with patients in the future
(from M = 4.25, SD = 0.60 to M = 4.53, SD = 0.50; p < 0.001; d
0.51).
As shown in Table 2, the exploratory factor analyses re-
sulted in 3 and 2 factor solutions for the self and peer assess-
ment instruments, respectively. In both cases two of the factors
were identified based on a previous factor analysis study as WH
and IA (Dannefer et al., 2005). The third self assessment factor
derived was labeled personal attributes (PA) as they reflect
items that describe individual’s attributes in asking for and
implementing feedback (item loading = 0.751), admitting mis-
takes or being truthful (0.634), and collaborative through the
sharing of information or resources (0.626). Although there are
common items between the self and peer assessment question-
naires that are associated with only the WH (items 1, 2, 3 and
14) or IA (items 4, 5, 12 and 13) subscales, the remaining items =

T. DONNON ET AL.
Table 2.
Two and three factor solutions for self and peer assessment instruments, respectively.
Self Assessment (n = 168) Peer Assessment (n = 1267)
Item Work
Habits
Interpersonal
Abilities Personal Work Habits
Interpersonal
Abilities
1) Consistently well prepared
2) Identifies and solves problems
3) Clearly explains reasoning processes
4) Demonstrates respect, compassion
5) Seeks to understand others/sensitivity
6) Takes initiative
7) Shares information with others
8) Seeks responsibility
9) Asks for and implements feedback
10) Trustworthy
11) Admits mistakes
12) Dress and appearance appropriate
13) Behaves appropriately
14) Thinks and works independently
0.622
0.666
0.679
0.343
0.485
0.619
0.792
0.671
0.499
0.682
0.840
0.371
0.534
0.626
0.439
0.751
0.561
0.634
0.776
0.811
0.759
0.654
0.539
0.673
0.443
0.686
0.841
0.793
0.486
0.425
0.515
0.705
0.687
0.525
0.740
Number of items for each factor
Cronbach’s α for each factor
Variance explained by each factora
5
0.60
20.1%
4
0.80
17.8%
5
0.77
15.7%
7
0.87
28.7%
7
0.86
28.6%
Note: aSelf and peer Assessment total variance is equal to 53.6% and 57.3%, respectively. Note that only item loadings greater than 0.32 are reported (i.e., accounting for
greater than 10% of the variance).
Figure 2.
Decision study Generalizability (G-) coefficients for 4 to 12 student
peer assessors.
Discussion
The major findings of the present study are that: 1) self as-
sessment of professional competence was significantly lower in
comparison with peer assessors on all questionnaire items, 2)
distinct from the 2 factor solution for the peer assessment ques-
tionnaire, the 3 factor solution for the self assessment includes
an additional subscale associated with personal attributes, 3)
women medical students were rated significantly higher either
by themselves or their peers on more items than were the men,
and 4) on a one year test-retest of the self assessment question-
naire, students’ self-reported rating were significantly higher
from year one to two on total and subscale scores.
The discrepancies found between self- and peer-reported as-
sessment across each of the items rated reflect a concern as to
why individual students tend to perceive that their professional
competencies are lower than the mean ratings provided by a
group of peers they interact with on a regular, if not daily, basis.
When investigated by quartile groups based on self assessment
totals, there appears to be a majority of medical students that
significant underestimate themselves in comparison with their
peers. This miscalibration effect found between the self and
peer assessment ratings is typical of physicians’ self and peer
assessment as well (Violato & Lockyer, 2006). It would seem
that the miscalibration of professional competencies that was
shown to be evident in experienced physicians begins early in
one’s medical career, as we see in the present results, and likely
reflects a general discrepancy found in human self assessment.
Although methods for the assessing of competencies such as
work habits, interpersonal abilities and personal attributes are
less well developed or tested, the peer assessment protocol and
15 item self and peer assessment forms provide a potentially
reliable and valid method to introduce sources of feedback that
can help medical students to reflect on and enhance their own
professional development. The findings in this study, however,
demonstrates the difficulty in developing MSF tools or ques-
tionnaires that can consistently measure similar constructs be-
tween different types of raters (e.g., self, peer, co-workers,
patients) as a function of observable behaviors (Lockyer &
Clyman, 2008). Therefore, one of the main limitations of the
use of the results is that there is some uncertainty as to the spe-
cific factors being measured as the self assessment question-
naire appears to be more multidimensional in that an additional
third factor was identified (i.e., personal attributes). Another
limitation is that overall students are left with the impression
from their peer groups that they are actually rated much higher
(or at the same level) on each of the 15 items than the self-
reported ratings provided on the corresponding self assessment
questionnaire (Colthart et al., 2008).
There is an expectation that medical schools need to provide
students with feedback related to their clinical and professional
performance. The current assessment formats for medical stu-
dents focus primarily on testing clinical knowledge and skills,
without any means of formative feedback for professional de-
velopment. The use of a self and peer assessment MSF process
26

T. DONNON ET AL.
in the initial years of medical school provides an opportunity
for students to become engaged in understanding how they are
performing on other aspects of their non-cognitive skills de-
velopment (i.e., ability to collaborate with others, communica-
tion effectiveness, managing their time and resources). Never-
theless, efforts to measure relevant constructs that have applica-
tion to their roles and responsibilities as future physicians are
still not well defined. With the move towards competency-
based frameworks in residency programs, MSF assessments
will need to better reflect measures associated with the key
competencies identified of practicing physicians (ACGME,
2013; Frank, 2005).
Acknowledgements
The authors acknowledge the students, staff and administra-
tion at the Office of Undergraduate Medical Education for their
continuing support in our research efforts to improve the qual-
ity of assessment methods and approaches used at our medical
school.
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Appendix.
Peer assessmenta questionnaire (Dannefer et al., 2005).
Instructions to the students:
Please rate this student based on your personal knowledge of the student and your own interactions with him/her. Note that 1 is the lowest rating and 5 is the
highest rating for each characteristic. If you have insufficient contact with the student to evaluate him/her on a particular characteristic, circle UA (unable to
assess).
Low/Unsatisfactory High/Exceptional
1
Consistently seems unprepared for sessions; presents minimal
amount of material; seldom supports statements with
appropriate references
12345UA
Consistently well prepared for sessions, presents
extra material, supports statements with appropriate
references
2 Overlooks important data and fails to identify or solve
problems correctly 12345UAIdentifies and solves problems using intelligent interpretation of data
3 Unable to explain clearly his or her reasoning process with
regard to solving a problem, basic mechanisms, concepts etc 12345UA
Able to explain clearly his or her reasoning process
with regard to solving a problem, basic mechanisms,
concepts etc.
4 Lacks appropriate respect, compassion and empathy 12345UAAlways demonstrates respect, compassion and
empathy
5 Displays insensitivity and lack of understanding for others’
views. 12345UASeeks to understand others’ views
6 Lacks initiative or leadership qualities 12345UATakes initiative and provides leadership
7
Doesn’t share information or resources; impatient when
others are slow to learn; hinders group process; tends to
dominate group
12345UA
Shares information or resources; truly helps others
learn; contributes to the group process; able to deter
to the group’s needs.
8 Only assumes responsibility when forced to or stimulated for
personal reasons; fails to follow through consistently 12345UA
Seeks appropriate responsibility; consistently
identifies tasks and completes them efficiently
and thoroughly
9 Does not seek feedback; defensive or fails to respond to
feedback 12345UAAsks classmates and professors for feedback and then puts suggestions to good use
10 Pleases superiors while undermining peers; untrustworthy 12345UAPresents him/herself consistently to superiors and
peers; trustworthy
11 Hides his or her own mistakes; deceptive 12345UAAdmits and corrects his or her own mistakes, truthful
12 Dress and appearance often inappropriate for the situation 12345UADress and appearance always appropriate for the
situation
13 Behavior is frequently inappropriate 12345UABehavior is always appropriate
14 Dependent upon others for direction with regard to his or her
learning agenda. 12345UADirects own learning agenda; able to think and work independently
15 I have concerns for his or her future patients 12345UA
I would refer my own family or patients to this
future physician or ask this person to be my
physician
Note: aThe corresponding self assessment questionnaire is identical, but written in the first person.
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