Fig. 1

Cultural Historical Activity Theory (CHAT) framework and the Miller’s Pyramid of Clinical Competence. The role of feedback is highlighted as mediating the residents’ interactions and activities towards increasing level of competence. Based on the work in Engestrom, Y. Learning by expanding: An activity-theoretical approach to developmental research. 2nd Ed. Helsinki: Orienta-Konsultit; 1987. and Miller GE. Assessment of clinical skills/competence/performance. Acad Med 1990;9:63–67