New ACGME Clinician Educator Milestones as a Roadmap for Faculty Development: a Position Paper from the Society of General Internal Medicine Education Committee

Abstract

Traditionally, clinician educators are tasked with the responsibility of training future physician workforce. However, there is limited identification of skills required to fulfill this responsibility and a lack of consensus on effective faculty development for career growth as a clinician educator. The newly released Accreditation Council of Graduate Medical Education (ACGME) Clinician Educator (CE) Milestones framework outlines important skills for clinician educators and provides the opportunity to create robust faculty development. In this paper, members of the Society of General Internal Medicine Education Committee discuss the importance of these CE Milestones, outline the novel themes highlighted in the project, and provide recommendations for proper application on both the individual and institutional levels to optimize faculty development. The paper discusses strategies for how to apply the CE Milestones as a tool to create a culture of professional growth and self-directed learning. Using a reflective approach, CE faculty and mentors can identify areas of proficiency and opportunities for growth, thereby creating individualized professional development plans for career success. Institutions should use aggregate CE Milestones data as a needs assessment of their faculty “population” to create targeted faculty development. Most importantly, institutions should not use CE Milestones for high-stakes assessments but rather encourage reflection by CE faculty and create subsequent robust faculty development programs. The ACGME CE Milestones present an exciting opportunity and lay an important foundation for future CE faculty development.

INTRODUCTION

Clinician educator (CE) faculty are at the helm of training the future workforce of physicians and require a unique skill set in several areas. Busy faculty often feel the tension in balancing their clinical responsibilities with their educational and administrative roles¹. This disconnect is furthered by a focus on traditional metric-level feedback (such as Relative Work Units, Readmission rates) for clinical productivity compared to a lack of metric data in the educational realm. With experience, faculty develop skills to integrate both the clinician and educator roles; however, early career faculty often lack clear guidance on their development as an educator. Few standardized, developmental structures exist to promote progressive longitudinal faculty development for clinician educators, further perpetuating the lack of guidance for career advancement for CE faculty^{2, 3}.

In August 2022, the American College of Graduate Medical Education (ACGME) launched the Clinician Educator Milestones for teaching faculty in collaboration with other national organizations including the Accreditation Council of Continuing Medical Education (ACCME), Association of American Medical Colleges (AAMC), and American Association of Colleges of Osteopathic Medicine (AACOM). This paper will herein refer to these new milestones framework as the ACGME Clinician Educator (CE) Milestones⁴. The ACGME CE Milestones provide a comprehensive list of fundamental skills and responsibilities for teaching faculty, especially those in medical education leadership⁴. Individual CE Milestones are developmentally modeled from novice to expert based on the Dreyfus model and highlight the skills at each stage for both individual faculty members and institutional leaders^{4, 5}. As a result, faculty members can reflect on each milestone and assess their level of skill. Ultimately, the milestones serve as a guide for individual faculty growth, allowing them to identify the next steps for progression in each milestone.

Additionally, these milestones have a parallel structure with the competency-based model introduced by ACGME in 2013 for all graduate medical trainees, thereby creating a culture of competency throughout the continuum of medical education⁶. Currently, residency milestones are used to monitor learners’ progress and facilitate early identification of learners’ challenges^{7, 8}. Similarly, clinician educator milestones offer several advantages including clarifying expectations for CE development, promoting reflection, and identifying specific faculty development areas for mentors and institutional leaders. This position paper from the Society of General Internal Medicine Education Committee discusses the novel themes in the ACGME Clinician Educator Milestones and provides recommendations for their application at the individual and institutional levels. The writing group consists of national medical educational leaders with five or more years of expertise in both undergraduate and graduate medical education from 8 different institutions in different regions of the USA. The authors in the writing group developed the 6 recommendations through an iterative process with several rounds of virtual group discussions over 12 months to reach a consensus. The paper was further reviewed by the chair of the ACGME CE Milestones Workgroup for additional input.

NOVEL THEMES IN THE CLINICIAN EDUCATOR MILESTONES

Throughout the list of milestones, certain themes are notably more prevalent in CE faculty development and discourse than in prior generations. Table 1 identifies these prevalent themes within the CE Milestones and maps each milestone to its corresponding theme. Themes were outlined by author AP and a consensus was reached with all authors through an iterative process. Each novel theme has multiple corresponding milestones as outlined in Table 1. Certain milestones such as Educational Theory and Practice 2 (Professionalism) contain language such that there is overlap with multiple themes and, thus, are listed in multiple places in Table 1.

Table 1.

Themes Outlined in the ACGME Clinician Educator Milestones⁴

Theme	Milestone
Well-being	Foundational 2 – Well-being Well-being – Well-being of self, learner, and colleagues
Diversity, Equity, and Inclusion	Foundational 3 – Barrier and bias mitigation Educational theory and Practice 2 – Professionalism Educational theory and Practice 4 – Feedback Diversity, equity, and inclusion Administrative 3 – Learning environment
Reflection for Personal Growth	Foundational 1 – Reflective practice and commitment to personal growth Educational theory and Practice 2 – Professionalism Educational theory and Practice 7 – Learner professional development
Familiarity with Learning Theory	Educational theory and Practice 1 – Teaching Educational theory and Practice 6 – Program evaluation Educational theory and Practice 8 – Science of learning
Assessment	Educational theory and Practice 3 – Learner assessment Educational theory and Practice 4 – Feedback Educational theory and Practice 5 – Remediation
Administrative	Administrative 1 – Administrative skills Administrative 2 – Leadership skills Administrative 4 – Change management
Scholarship	Educational theory and Practice 9 – Scholarship

One such novel theme is Well-being, and the inclusion of this theme is significant due to the high prevalence of burnout in medical training and the physician workforce^{9, 10}. Importantly, the milestones emphasize faculty members’ promotion of well-being in self, learners, and colleagues. Its inclusion as a milestone elevates well-being as an essential part of the rubric for high-quality clinician education. We believe this attention to well-being and the role-modeling of wellness for junior faculty and trainees is a crucial step in the creation of a culture of wellness. Ultimately, the adoption of the well-being milestones at the institutional level by leadership can facilitate achieving such a culture.

Another important theme in the clinical educator milestones includes skills in Diversity, Equity, and Inclusion (DEI). DEI is increasingly recognized as a national issue in medical training¹¹. Importantly, the milestones discuss faculty members’ competency in recognizing the presence of personal and systemic bias, the impact of bias on patient care, and the impact of bias on the learning environment. We believe the inclusion of these milestones sends the message that all CE faculty must develop skills to promote diversity and inclusion, and institutions should have resources for all faculty to develop such skills. Such a cultural shift will require time and infrastructure; these milestones lay the groundwork for such a change.

Reflection for Personal Growth is a third important theme highlighted in the milestones. The milestones highlight faculty members routinely reflecting on their personal performance, seeking feedback with a growth mindset, and contributing to learner professional development as a mentor or coach. We believe this is an important step in promoting self-directed learning skills in faculty and learners. These milestones emphasize the message of how a paradigm shift towards a growth mindset is necessary to develop trainees into master adaptive learners for the healthcare system of the future¹².

APPLICATION OF THE CE MILESTONES

Recommendations for Individual Clinician Educator Faculty

Recommendation 1: the new CE Milestones are ideally suited as a tool for individual faculty to perform periodic self-assessment and reflection on their areas for professional growth.

CE Faculty Vignette: Dr. Shah receives a summary of last year’s evaluations. She decides to specifically spend one administrative afternoon to complete a reflection exercise that focuses on reviewing comments through the lens of competency as defined in the CE Milestones. She looks for consistent themes in comments to identify areas where she did well and opportunities for growth. She specifically takes notes that she can refer to in the future and discuss with her mentors. (Universal Pillar 1: Reflective Practice and Commitment to Personal Growth)

Reflection has been identified as a key component of professional identity formation and is increasingly promoted as a means for ongoing professional development¹³. The new CE Milestones are best applied as a reflection tool for CE faculty and their supervisors, mentors, and institutional leaders. Such application is similar to how milestones are applied in resident training across several specialties including the new internal medicine ACGME milestones 2.0¹⁴. Indeed, literature on the ACGME Milestones for trainees cites their value for residents to self-assess their own competencies, for advisors to identify learning gaps, and for programs to gauge resident learning progress compared to the Dreyfus model of skills attainment^15–18.

Using CE Milestones with the purpose of reflection offers several advantages. Self-reflection can lead to the creation of goals to further enhance the CE skills and identify areas in which the CE faculty already excel^{19, 20}. Faculty self-reflection of CE Milestones competency can be coupled with the validated Teaching Perspectives Inventory to provide insight into one’s teaching style and self-directed learning on teaching skills²¹. Additionally, faculty self-assessment can span beyond distinct teaching skills to other relevant competencies in educational research, leadership, and curriculum development as detailed in the CE Milestones. To achieve these goals, milestones can be used in written exercises to stimulate internal critical appraisal or be reframed to prompt guided self-reflection by faculty. Ultimately, a reflective approach will enhance the faculty’s own professional identity formation and can help them impart those principles to trainees.

• Recommendation 1a: individual CE faculty can use the CE Milestones to identify areas in which they have achieved proficiency or expertise.

CE Faculty Vignette: Dr. Shah notes that several students commented that she was able to make effective teaching points in the clinic and on rounds. Learners viewed her chalk talks positively (Educational and Theory Practice 1: Teaching and Facilitating Learning). Students in her small group for the Problem-Based learning second-year course noted that she created a positive learning environment (Educational and Theory Practice 10: Learning Environment). She had also started a resident-as-teacher session for second-year residents which was mentioned in several positive comments (Educational and Theory Practice 11: Curriculum).

The value of the CE Milestones as an impartial tool should not be underestimated. CE faculty can use the objectivity of this tool to identify areas of proficiency or expertise. This can be advantageous for several reasons such as providing CE faculty with a valid metric to assess their skills. The milestones serve as an unbiased measure of CE achievement, which may help to mitigate bias and imposter syndrome. Imposter syndrome has been associated with burnout, poor resilience, and self-doubt²². CE Milestones provide faculty with the much-needed validity in their skills to overcome this barrier. As an objective tool, CE Milestones can also help faculty self-assess their proficiency in a skill set required for a new position or opportunity. Ultimately, the milestones can increase the workplace satisfaction of CE faculty by overcoming imposter syndrome and hesitancy for self-promotion.

• Recommendation 1b: individual CE faculty can use the CE Milestones to identify areas of opportunity for continued self-growth and professional improvement.

CE Faculty Vignette: Dr. Shah also notes that some learners commented that her feedback was not specific and actionable. They felt that her feedback did not provide them with a clear pathway for improvement (Educational Theory and Practice 3 and 4: Learner Assessment and Feedback). Evaluations mention that her feedback comments are vague without specific examples of behaviors. Dr. Shah also notes that her teaching evaluations addressing the facilitation of learning (Educational Theory and Practice 1: Teaching and Facilitating Learning) from students differ from those of her residents. Resident evaluations point out that Dr. Shah could improve the teaching points she makes on rounds and a lot of her teaching points are basic.

The CE Milestones can further help CE faculty identify opportunities for growth. Given the novice to expert structure of the milestones, CE faculty can recognize domains where they have not yet achieved mastery. Such identification of undeveloped skills will allow CE faculty to seek further development and instruction in these domains and approach their career development with a growth mindset. Such an approach can help create master educators with a strong skill set, leading to robust medical training.

• Recommendation 2: mentors and supervisors should work with individual faculty to help build individualized learning plans and/or growth mindset coaching interventions.

CE Faculty Vignette: Dr. Perez, who is a medical education leader at the institution, has been serving as a peer mentor for Dr. Shah since she is interested in pursuing a career in medical education. They confer on how Dr. Shah could continue to enhance her skills in providing feedback. Dr. Perez reviews how Dr. Shah engages her learners in feedback. Per Dr. Shah, she usually conducts formal feedback conversations 1–2 times during an inpatient rotation and struggles to do informal feedback in the clinic. Dr. Perez provides tools for giving learners in-the-moment feedback. Additionally, Dr. Perez provides resources for faculty development on feedback through the institutional Academy of Medical Educators.

For resident evaluations, they ask a respected coach/colleague to observe teaching rounds. After the rounds, the coach asks Dr. Shah to reflect on the session. Dr. Shah notes that there were substantial bidirectional discussions about all their patients. The coach prompts Dr. Shah to reflect on who participated in the discussion, leading Dr. Shah to realize that most of the discussion was with the medical students, leaving the residents seemingly disengaged. Using the milestones, Dr. Shah sets “using scholarly teaching methods for varied levels of learners” as her CE goal. With her coach, she selects 1 or 2 methods that she will incorporate into future bedside teaching, with the goal of involving all levels of learners, thus creating her personal individualized plan for professional growth.

Self-guided reflection based on CE Milestones can serve as an important tool not only for individual faculty but also mentors and supervisors. The novice to expert model and the emphasis on reflection within the milestones set the stage for growth mindset coaching for CE faculty by mentors and supervisors. In the process of guided self-reflection, we propose these milestones be implemented in a proactive growth mindset coaching context. Coaches can work to build rapport and mutual respect with CE faculty and provide thoughtful feedback in the milestone areas self-identified by the faculty member. Longitudinal relationships with coaches can help CE faculty feel respected and accurately self-assess their performance while applying the feedback provided^{23, 24}. This can be done in a pre-meeting review of the milestones followed by a one-on-one or a small group meeting with coaches. Alternatively, growth mindset coaching could occur in a guided discussion of performance based on milestones led by a faculty coach. Ultimately, such a coaching relationship can lead to an individualized plan for professional development (IPPD) for individual CE faculty members. The ACGME Supplemental Guide for CE Milestones provides adaptable toolkits and additional resources for individual faculty to develop IPPD²⁵.

• Recommendation 3: individual CE faculty can seek opportunities to expand their skill set in new emerging domains as defined in the CE Milestones

CE Faculty Vignette: through self-reflection, Dr. Shah wonders if she has been a passive bystander in team communication and if she has an implicit bias when she is filling out her evaluations. Dr. Shah completes mandatory bias training required by her institution and reaches out to the newly appointed Director of Diversity of Equity and Inclusion. Dr. Shah asks about resources that could help her develop skills to help with implicit bias when giving feedback and evaluating learners (Universal Pillar 3 Recognition and Mitigation of Bias; Diversity, Equity, and Inclusion in the Learning Environment).

The Milestones 2.0 expectation of graduating residents being “ready for autonomous practice” does not preclude the need for lifelong learning and ongoing professional development of practicing physicians¹⁴. Similarly, the concept of lifelong learning applies to academic faculty who are teaching the next generation of physicians. The CE Milestones include new areas of focus in a wide range of domains that facilitate diversity and a holistic review of the CE faculty skill set. These new areas include wellness and DEI amongst others. Additionally, certain CE Milestones include domains where CE faculty can expand beyond specific teaching skills to distinct competencies in educational research, academic leadership, and curriculum development. Through these new areas, CE faculty can continue their journey of self-directed learning.

Recommendations at the Institutional Level

Recommendation 4: institutional leaders should utilize the new CE Milestones to tailor faculty development programs to the professional needs of CE faculty.

Strategic application of the CE Milestones at the institutional level will be critical for faculty development. Notably, we believe that the ACGME CE Milestones are not intended to be prescriptive but rather send the message that institutions need to build an infrastructure where CE faculty can develop in a progressive manner creating a culture of lifelong learning. This aligns with resident milestones where granular steps are not outlined and, instead, the steps of progression for a learner in a positive learning environment are highlighted^{6, 14}.

Medical education leaders and institutional department chairs can apply these milestones to design robust professional development for CE faculty thereby creating a supportive environment for CE faculty. Institutional and medical education leaders should adopt the milestones to determine domains where CE faculty at their own institution need growth. We propose institutions and faculty development teams utilize aggregate data on milestones as a form of needs assessment to determine what domains of education might best aid their diverse group of faculty. Furthermore, departmental and divisional leaders can review their faculty’s collective milestones to aid in focusing needs for recruitment and divisional/departmental growth.

One example of an institutional application of CE Milestones comes from the Department of Family Medicine at the University of Tennessee Knoxville (UTK). The team has successfully created a model where CE Milestones were implemented as a standardized set of educational milestones to provide guidance on their faculty scholarship and professional development trajectory. Their innovative tool has allowed for individualized feedback and direction for faculty development, defined goals for scholarly work, and identified areas for mentorship of their CE faculty. Academic faculty, particularly new and junior faculty, demonstrated increasing knowledge of the expectations of a CE at the institution. UTK institutional leaders acknowledge the generalizability of these uniform milestones to other medical specialties and plan for adoption by other departments²⁶.

• Recommendation 5: institutions should not apply the CE Milestones to high-stake assessments such as credentialing, FTE allotment, leadership appointments, or promotion determination.

CE faculty value promotion but also perceive barriers towards academic advancement given the strong emphasis placed on research, and the more well-established physician-investigator pathway in academic medicine^{27, 28}. CE Milestones outline the skills of teaching faculty and, as such, could potentially impact their promotion and academic advancement. At this time, we advise against using the CE Milestones for high-stakes assessment of CE faculty such as benchmarks for promotion, full-time equivalent effort allotment, or consideration for leadership positions. No studies currently exist to understand or validate the role of the CE Milestones on faculty readiness for promotion or educational leadership. Without judicious investigation and validation studies, institutional application of milestones for the assessment of CE faculty could create an institutional culture of a fixed mindset and become punitive for CE faculty.

Further evidence against the use of CE Milestones for high-stakes assessment comes from the milestone-based UTK faculty development tool. UTK educational leaders noted that achievement in a higher level of competency did not always translate to academic career success or advancement. Hence, they too cautioned against the use of milestones to define the academic success of individual teaching faculty and reinforced its use as a tool for faculty professional development²⁶.

Other high-stakes assessments for CE faculty include hospital credentialing, medical licensing, or recertification. In the spirit of faculty growth, the ACGME itself has already stated that its new CE Milestones will have no accreditation implications for institutions⁴. In the future, if a new CE pathway becomes available within the ABIM Maintenance of Certification based on these CE Milestones, we propose that this pathway could serve as a unique opportunity for professional self-growth and self-directed learning by CE faculty. We reiterate our recommendation that such a pathway should not tie to requirements for hospital credentialing, medical licensing, or recertification. Rather than CE Milestones being applied to high-stakes assessments, we propose that they be used as a reflection tool and professional guide for career readiness by individual CE mentors and institutional leaders. Such an application of the CE Milestones will help CE faculty grow and prepare them to meet institutional or national standards for the high-stakes assessments discussed above.

• Recommendation 6: institutional and national leaders should avoid the wide adoption of the CE Milestones across all institutional continuing medical education (CME) activities and focus its application to CME activities specific to the teaching skills and professional growth of CE faculty.

With the advent of the CE Milestones, a common language on outcome-based education and competence now exists across the continuum of UME, GME, and CME for academic faculty. Its universal set of teaching competencies offers educational directors a systematic and structured approach to building continual learning opportunities for CE faculty. In fact, the new CE Milestones align well with many of the ACCME core criteria for educational planning and evaluation. Noteworthy ones include “CME activities [on] educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners” and the development of “activities/educational interventions in the context of desirable physician attributes (competencies)”²⁹.

Yet, questions remain on how best to operationalize the CE Milestones framework for institutional faculty development programs. Translating the CE Milestones competencies into ACCME standards is no easy feat. Critics of the ACCME process cite issues with high costs, administrative load, legitimacy to real-life practice, and the disconnect from GME training to clinical practice³⁰. With these multitudes of operational challenges, we recommend against widespread adoption of the CE Milestones across all institutional CME activities. Instead, we encourage focused application and strategic implementation of the CE Milestones to CME activities specific to the teaching competencies and the career growth of CE faculty. Institutional leaders of CME and faculty development must work collaboratively to align the CME learning activities on teaching-related skills to the competencies of the CE Milestones framework. These experts in assessment and educational strategies will need to further ensure its sustainability, validity, and authenticity to CE faculty. For aspirational CME providers, ACCME offers a pathway to achieve Accreditation with Commendation utilizing criteria areas that align well with the ACGME CE Milestones framework³¹. These commendation criteria include, but are not limited to, the creation of individualized educational plans for learners and the demonstration of improvement in learners’ performance^{32, 33}.

At the national level, several teaching certification programs exist within individual medical societies for CE faculty to attain progressive teaching expertise. These include, but are not limited to, the SGIM Teaching Educators Across the Continuum of Healthcare (TEACH) program, the Harvard Macy Institute Program for Educators, and the Association of American Medical Colleges Medical Education Research Certificate (MERC) program. These programs provide a shared community of CEs for scholarship, networking, and collaboration. The CE Milestones framework offers the potential to consolidate and elevate these individual CE faculty development programs under one overarching standard of core teaching competencies. Ultimately, a more focused application of CE Milestones to programs focusing on teaching skills can help create more robust targeted faculty development for CE faculty.

CONCLUSION

In conclusion, we support the broad implementation of the comprehensive ACGME CE Milestones that outline the breadth of skills required to be an effective CE faculty. The application of CE Milestones presents certain opportunities and challenges for the future. Widespread implementation of CE Milestones will help identify the next steps and any potential limitations of the milestones. The CE Milestones present a tremendous opportunity for creating robust faculty development including those in emerging medical education areas that will provide value to trainees at all levels. A potential risk with CE Milestones is their application to summative high-stakes decisions such as academic promotion and leadership roles. The authors discourage such use of the CE Milestones and recommend its use as a self-reflection guide for CE faculty towards their career goals. Applying CE Milestones through a growth mindset lens will change the culture and encourage CE faculty to develop professional skills for continuous improvement.

Declarations

Conflict of Interest:

The authors have no financial disclosures.