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FELLOWS-IN-TRAINING & EARLY CAREER PAGE

Milestones and the NextAccreditation SystemWhat Does it Mean to the Fellows?

Chandrasekar Palaniswamy, MD

I n 1999, the Accreditation Council for GraduateMedical Education (ACGME) identified 6 corecompetency domains required during residency

training for all specialties. These competenciesinclude patient care, medical knowledge, practice-based learning and improvement, interpersonal andcommunication skills, professionalism, and systems-based practice. The traditional model of residencyand fellowship training was defined by a curriculumthat was based on time in training rather than onattainment of competency. This model largelyfocused on defining the “finish line” of training bydemonstrating acquisition of specific knowledgethrough certification examinations. Acquisition ofskills and attitudes were not considered in this modelin defining the completion of training. The newermodel of competency-based training focuses onachievement of specific goals and objectives of thecurriculum.

In 2007, the American Board of Internal Medicineand the ACGME convened a task force that culmi-nated in identification of “milestones” forcompetency-based training (1). Milestones are a setof specific, observable skills, attitudes, and know-ledge that represent important intermediate pointsacross the 6 ACGME core competencies. Thesemilestones provide a criterion-based framework forperformance to help training programs assess theprogression of a trainee. This aims to producehighly competent physicians to meet the expecta-tions and health care needs of the public. Theprograms are now required to demonstrate thattheir trainees have acquired these behaviors to

From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn

School of Medicine at Mount Sinai, New York, New York.

advance in training. The Internal Medicine Subspe-cialty Milestones Project lists 23 milestones that aredesigned for programs to use in a semiannualfashion to assess fellows’ performance (2). They aresummarized in Table 1. The milestones are arrangedin columns of progressive stages of competence: notyet assessable, critical deficiencies, ready for unsu-pervised practice, and aspirational (exceptional).The column “ready for unsupervised practice” isdesigned as the graduation target, but it does notrepresent a graduation requirement at this point.The Next Accreditation System mandates thatmedical subspecialty training programs now docu-ment achievement of competency through mile-stones, representing a paradigm shift in the processof graduate medical education in the UnitedStates (3).

In a specialty such as cardiology, where pro-cedures require a combination of motor skills, judg-ment, and medical knowledge, accurate assessmentof competency can be particularly challenging.Although procedural skills are not explicitly includedas 1 of the core competencies, it can be surmised thatthis will include aspects of all 6 competencies. It isimperative to develop an objective tool for assess-ment of competency in common procedures. The besttools are those that consistently measure the perfor-mance objectives with minimal sampling error, evenwith different evaluators. For instance, a sampleobjective assessment of technical skill for cardiaccatheterization can include the following: appropri-ateness of indication for the procedure, weighing therisks versus benefit of the procedure, knowledge ofrelevant anatomy, familiarity with equipment, per-formance of the procedure, interpretation of angio-graphic data, management decisions based onresults, and monitoring for complications. Feedback

TABLE 1 Internal Medicine Subspecialty Reporting Milestones

Patient care

1. Gathers and synthesizes essential and accurate information to define eachpatient’s clinical problem(s)

2. Develops and achieves a comprehensive management plan for each patient

3. Manages patients with progressive responsibility and independence

4a. Demonstrates skill in performing and interpreting invasive procedures

4b. Demonstrates skill in performing and interpreting noninvasive proceduresand/or testing

5. Requests and provides consultative care

Medical knowledge

6. Possesses clinical knowledge

7. Knowledge of diagnostic testing and procedures

8. Scholarship

Systems-based practice

9. Works effectively within an interprofessional team (e.g., with peers,consultants, nursing, ancillary professionals, and other support personnel)

10. Recognizes system error and advocates for system improvement

11. Identifies forces that impact the cost of health care, and advocates for andpractices cost-effective care

12. Transitions patients effectively within and across health delivery systems

Practice-based learning and improvement

13. Monitors practice with a goal for improvement

14. Learns and improves via performance audit

15. Learns and improves via feedback

16. Learns and improves at the point of care

Professionalism

17. Has professional and respectful interactions with patients, caregivers, andmembers of the interprofessional team (e.g., peers, consultants, nursing,ancillary professionals, and support personnel)

18. Accepts responsibility and follows through on tasks

19. Responds to each patient’s unique characteristics and needs

20. Exhibits integrity and ethical behavior in professional conduct

Interpersonal and communications skills

21. Communicates effectively with patients and caregivers

22. Communicates effectively in interprofessional teams (e.g., with peers,consultants, nursing, ancillary professionals, and other support personnel)

23. Appropriate utilization and completion of health records

Adapted from the Internal Medicine Subspecialty Milestones Project (2).

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about procedural performance should be providedto the fellow as soon as possible after the procedureis completed. With progressive experience andcompetence, the fellow can be assigned more com-plex procedures.

Although the adoption of competency-basedtraining will enhance opportunities for early identifi-cation of struggling fellows, this system is not withoutflaws. Significant anomalies in the learning curve doexist, where some fellows may be slow learners butultimately end up matching or outperforming theirpeers before the end of their training. Qualities such ashumanism, selflessness, and professionalism aredifficult to measure in objective terms.

In an ideal training environment, the fellowsshould feel free to confront their weaknesses withoutfear of failure. When performance becomes the pri-mary criterion to determine the progression throughtraining, a fellow may purposefully hide his or herweakness from the evaluator for short-term gains.This may lead to the incorrect conclusion that a fellowis making appropriate progress and leave little op-portunity for rectification of his or her weakness. Thetrue purpose of training may not be achieved in thatcase. This is more likely if the summative evaluationof curricular milestones is taken by a few evaluators.A clinical competency committee that includes coreteaching faculty and representatives from thedifferent disciplines should be involved in makingdecisions on progression through training. Inaddition to faculty evaluation, assessments frompatients, nurses, and staff should be considered incompetency-based evaluation. The trainees alsomight benefit from a structured mentoring program,where confidentiality between mentor and traineewould allow trainees to feel more comfortableexpressing their weaknesses and seeking suggestionsto fix them. It should be ensured that ethnic minor-ities, women, and international medical graduatesreceive mentoring and support that is empathetic andsensitive to their needs.

One of the major threats to the validity ofmilestone-based training is evaluator bias. The su-pervising faculty needs to be trained on the use ofmilestones in competency assessment with stan-dardized criteria. Frequent formative feedbackshould be provided on the basis of direct observationof performance and specific behaviors that are ex-pected should be explicitly stated. Finding the rightbalance between direct supervision and providingautonomy to the fellow is crucial.

It is essential that the milestones also incorpo-rate skills required for the next generation of

health care delivery, including leadership training,respecting the skills of other practitioners, resourcemanagement, health policy and regulation, riskmanagement, relationship with industry, timemanagement, stress management, conflict manage-ment, and providing performance feedback to peersand juniors. Milestones are unlikely to replaceboard examinations; however, they may be a goodstarting point for an innovative design of boardexaminations. The next phase of competency-basedassessment will probably involve short-track path-ways for suitably competent fellows. Some wouldargue that a 3-year training period is necessary forsufficient exposure to diverse aspects of cardiology,for adequate longitudinal care of a panel of

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patients, and to refine the skills needed to care forthese patients. A 2-year short-track pathway maymitigate the nation’s shortage of cardiologists andallow for better utilization of the availableresources.

As we shift toward milestone-based evaluation incardiology fellowship training, we need to activelyparticipate with the ACGME to improve the new

evaluation system before high-stakes decisions arebased upon it.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Chandrasekar Palaniswamy, Icahn School of Medicineat Mount Sinai, One Gustave L. Levy Place, P.O. Box1030, New York, New York 10029. E-mail:chandrasekar.palaniswamy@mountsinai.org.

RE F E RENCE S

1. Green ML, Aagaard EM, Caverzagie KJ, et al.Charting the road to competence: developmentalmilestones for internal medicine residencytraining. J Grad Med Educ 2009;1:5–20.

2. The Internal Medicine Subspecialty MilestonesProject. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineSubspecialtyMilestones.pdf. AccessedJuly 29, 2014.

3. Nasca TJ, Philibert I, Brigham T, Flynn TC. Thenext GME accreditation system—rationale andbenefits. N Engl J Med 2012;366:1051–6.