Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
The Supplement to the March 2014 issue of the Journal of Graduate Medical Education features the educational Milestones for 19 Accreditation Council for Graduate Medical Education (ACGME)–accredited specialties and the Transitional Year. These specialties will enter the Next Accreditation System (NAS) on July 1, 2014. Included with each set of Milestones is a description of their development, which also discusses the architecture of the Milestones, their envisioned use in resident evaluation and program improvement, and the pilot studies to date that have assessed the Milestones' psychometric properties and feasibility of implementation and use. A supplement to the March 2013 issue of the Journal featured the Milestones for the 7 specialties that entered the NAS on July 1, 2013, along with an introduction to the Milestones,1 and a description of Milestone development for the first 7 specialties that also discussed their development and essential properties.2
The table shows key data items for the educational Milestones for all accredited specialties and the Transitional Year. Columns in the table show the organization of the Milestones, the number and type of Milestone sets for each specialty, information on the origin of the Milestones for the 4 cross-cutting competencies, and other relevant information such as whether the Milestones include suggestions for assessment.
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Milestone Organization for All ACGME-Accredited Core Specialties and the Transitional Year
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The table is intended as a reference for the first set of educational Milestones that will be reported as part of NAS reporting of educational outcomes. The aim is to show similarities and differences among these Milestone sets, and to provide a historical reference for the initial Milestones developed by the educational community in each specialty.
Number of Milestones for Patient Care and Medical Knowledge
The Milestones in the table show a variety of approaches to the initial Milestone sets. The number of subcompetencies for the 6 ACGME competencies (Patient Care/Technical Skills, Medical Knowledge, Systems-Based Practice [SBP], Practice-Based Learning and Improvement [PBLI], Professionalism [PROF], and Interpersonal and Communication Skills [ICS]) ranges from 10 for Allergy and Immunology, a specialty entered after completion of a prior residency and 12 for Diagnostic Radiology, to 41 for Orthopaedic Surgery. The number of Milestone sets for Patient Care/Technical Skills ranges from 2 for Diagnostic Radiology to 18 (Neurology); and the number for Medical Knowledge spans 1 (Anesthesiology, Emergency Medicine, Pediatrics, Physical Medicine and Rehabilitation, and Urology) to 16 for Orthopaedic Surgery. The number of Milestone sets for the 4 cross-cutting competencies SBP, PBLI, PROF, and ICS also varies considerably among specialties.
Milestone Organization
For many medical and hospital-based specialties the Milestone sets are organized around Elements of Patient Care and the Physician's Role, while for most surgical/procedural specialties the Milestone sets are organized by Diagnoses, Disease Processes, and Technical/Procedural Skills. Seven specialties (Medical Genetics, Neurology, Ophthalmology, Otolaryngology, Preventive Medicine, Psychiatry, and Surgery) opted for a hybrid approach that combines both Elements of Patient Care and the Physician's Role and Diagnoses, Disease Processes, and Technical/Procedural Skills. Two specialties (Internal Medicine and Pediatrics) organized their Milestone sets around the 6 competency domains, and either as part of the work of the Milestone working group or in a separate effort, mapped their specialty Milestones to Entrustable Professional Activities (EPAs).3,4
For the procedural specialties that opted for Milestone sets organized around diagnoses, disease processes, and technical skills, the level of detail in this approach to Milestone organization may offer added clarity in terms of residents' acquisition of competence to perform common surgical operations and tasks. At the same time, the Milestone working groups using this approach acknowledged that their approach used a sampling methodology and does not encompass the breadth of practice in the specialty. In addition, the level of detail for this approach to Milestone organization may result in a greater assessment burden for programs and their Clinical Competency Committees (CCCs). Use of Elements of Patient Care and the Physician's Role and Diagnoses, Disease Processes, and Technical/Procedural Skills resulted in Milestone sets that appear to be superior in capturing the breadth of medical practice in the specialty, but often the individual Milestones are less likely to be around a specific set of clearly observable characteristics, and may be more open to interpretation about the level of performance that constitutes attainment of a given Milestone. This may result in added preparatory work for CCCs to ensure a common perspective on Milestone attainment to ensure consistent ratings across committee members, residents, and instances of CCC assessment. Use of EPAs in Milestone implementation introduces a meaningful way of organizing and integrating Milestones to correspond with higher-level tasks performed by residents.4,5
Linkage to American Board of Medical Specialties Member Board Examination or Specialty Curricula
In 8 specialties, the Medical Knowledge and Patient Care/Clinical Skills subcompetencies were explicitly linked to key components of the American Board of Medical Specialties Member Board Examination (Emergency Medicine, Neurological Surgery, Obstetrics and Gynecology, Plastic Surgery, and Thoracic Surgery), the In-Training Examination (Urology), or to a validated curriculum developed by the specialty (Neurological Surgery, Surgery).
Milestone Sets for the 4 Cross-Cutting Subcompetencies
The Milestone sets for the cross-cutting Milestones for most specialties were adapted from a generic set of sample Milestones developed by an ACGME Expert Panel. The degree of adaptation varied among specialties and by the type of training program (“true” core program, educational program entered after completion of a prior residency [eg, Allergy and Immunology, Colon and Rectal Surgery, and Medical Genetics]), or a preparatory program (eg, the Transitional Year). Several specialties developed their own Milestones for SBP, PBLI, PROF, and ICS, and a few used a mixed model with some Milestone sets from the Expert Panel and some developed by the Milestone Working Group.
Added Features
Seven Milestone working groups provided suggestions for tools and situations to assess the Milestones (Emergency Medicine, Plastic Surgery, Preventive Medicine, Radiation Oncology, Thoracic Surgery, the Transitional Year, and Urology); these assessments are not mandated. Three Milestone working groups developed specific examples for use in preparing CCC members for their role in Milestone scoring (Colon and Rectal Surgery, Nuclear Medicine, and Otolaryngology). One specialty, Psychiatry, offered ample footnotes to contextualize the specialty's educational Milestones as well as to offer references from the medical education literature. Four specialties developed additional Milestones to be used exclusively in resident assessment, remediation, or curriculum enrichment (Internal Medicine, Ophthalmology, Pediatrics, and Physical Medicine and Rehabilitation).
Conclusion
The goal of the educational Milestones is to assure that graduates of accredited programs have attained the knowledge and skills required for unsupervised practice in their specialty, while for residents in training, the Milestones will enhance education and resident assessment and will contribute to a system that assures the safety and quality of care of patients cared for by residents.
The educational Milestones in the table should be viewed as a starting point. This information will be useful given the envisioned evolution of the educational Milestones as additional information is gleaned from pilot projects, assessment studies, and the use of the Milestones by programs and the ACGME.
Footnotes
All authors are at the Accreditation Council for Graduate Medical Education. Ingrid Philibert, PhD, MBA, is Senior Vice President, Field Activities; Timothy Brigham, MDiv, PhD, is Senior Vice President, Education; Laura Edgar, EdD, CAE, is Senior Associate Director, Outcome Assessment; and Susan Swing, PhD, is Vice President, Outcome Assessment.
References
- 1.Sullivan G, Simpson D, Cooney T, Beresin E. A milestone in the milestones movement: the JGME milestones supplement. J Grad Med Educ. 2013;5(1 suppl 1):1–4. doi: 10.4300/JGME-05-01s1-08. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR, et al. Educational milestone development in the first 7 specialties to enter the next accreditation system. J Grad Med Educ. 2013;5(1):98–106. doi: 10.4300/JGME-05-01-33. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Alliance for Academic Internal Medicine Education Redesign Committee. Internal medicine end of training EPAs. http://www.im.org/AcademicAffairs/milestones/Pages/EndofTrainingEPAs.aspx. Accessed December 12, 2013. [Google Scholar]
- 4.Carraccio C, Burke AE. Beyond competencies and milestones: adding meaning through context. J Grad Med Educ. 2010;2(3):419–422. doi: 10.4300/JGME-D-10-00127.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice. Acad Med. 2007;82(6):542–547. doi: 10.1097/ACM.0b013e31805559c7. [DOI] [PubMed] [Google Scholar]