When a physician's license to practice is at stake, professional acceptance and legal challenge are concerns for an organization undertaking competency assessments for practicing physicians. In 1995 the Physician Review and Enhancement Program (PREP), a program of McMaster University sponsored by the College of Physicians and Surgeons of Ontario, underwent an external review by evaluation experts. As a result, one of the four assessment tools, the Structured Office Oral, was dropped, as it was insufficiently structured to be reliable and because it did not add significantly to the other tools. The content of all assessment tools was revised based on a PREP-developed blueprint for family practice. The multiple-choice questions (MCQs) were upgraded through collaboration with Canada's physician-accrediting body, the Medical Council of Canada (MCC), by the physician assessors, who chose MCQs according to the blueprint from the MCC question bank. The standardized-patient assessment was also refined by these physicians, who developed scenarios of standardized clinical cases with predefined performance criteria. Finally, through collaboration with the American Board of Emergency Medicine, a chart-stimulated recall test, in which the physician's own patient records are used to assess the physician's practice behavior, was restructured to ensure objectivity in standardization and interpretation. The result of these changes in the assessment tools is a more standardized and structured program of assessing physicians' competencies.