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Physicians debate ACGME's Milestones initiative

The Accreditation Council for Graduate Medical Education’s Milestones initiative and its role in internal medicine are a source of debate for physicians, with some looking forward "to continuing to refine the milestones" and others calling for "a simplified assessment of proficiency."

According to recently published findings, many physicians agree the Milestones program is challenging to implement, making it an inaccurate method of educating and assessing residents’ performance. However, Accreditation Council for Graduate Medical Education (ACGME) asserts it is taking the necessary measures to mend the issue and enhance the Milestones program.

“Milestones are part of a continuous quality improvement model for education and accreditation in residency and fellowship programs,” Eric S. Holmboe, MD, of the ACGME in Chicago, and colleagues wrote in an opinion essay on the subject.

According to Holmboe and colleagues, Milestones provides a framework to guide and assess residents on six general competencies in order to meet the 21st century health care needs before entering solo practice. These include patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice.

In an opposing viewpoint article, Ronald M. Witteles, MD, of the Department of Medicine at Stanford University School of Medicine, and colleagues wrote, “Although the theory underlying Milestones seemed sensible, the concept broke down in implementation.”

They continued, “There is a disconnect between the educational theorists who thought this to be a good plan and those on the ground level trying to implement the theory.”

The authors added, “Many viewed the system as meaningless and expensive without any clear evidence that it made them better physicians who delivered better care.”

Witteles and colleagues argue that with each Milestone containing up to 18 performance descriptors, evaluators from large internal medicine programs with approximately 120 trainees do not have the time to effectively assess and discuss each Milestone with their trainees. They estimated each evaluator would have to dedicate 7 standard work-weeks solely to completing Milestones assessments.

In addition, Witteles and colleagues point to recent evidence that suggests “clinical competency committees are taking the expedient (and practical) path for evaluations, largely checking the boxes based on where trainees are supposed to be rather than based on actual meaningful performance data.” Furthermore, Witteles and colleagues report that many residents and evaluators are unaware of ACGME’s Milestones or do not have a clear understanding of it.

Holmboe and colleagues proclaim the ACGME has fully recognized that effective implementation of Milestones is the greatest challenge for residency programs. Many evaluators have not been trained in newer competencies which further complicates the issue, Holmboe and colleagues wrote.

However, according to Holmboe and colleagues, “the ACGME has been engaged in a multifaceted effort to evaluate, refine, revise and improve the Milestones initiative, including visits to many institutions and participation in many specialty society meetings.”

Witteles and colleagues argued, “A simplified assessment of proficiency in a small number of core skill sets (often called ‘entrustable professional activities’) would likely prove to be more honest, efficient and accurate [than Milestones] — with a fraction of the bureaucracy. Three years into the present experiment, the conclusion is clear: The Milestones are an administrative millstone. The ACGME should restore its promise to help program directors mentor residents rather than manage programs.”

“We are still in the early days of using the Milestones to achieve better educational outcomes for trainees,” Holmboe and colleagues concluded. “[The] Milestones initiative will provide national performance data on competencies beyond medical knowledge that were not previously available.” – by Alaina Tedesco

Disclosure s : Holmboe reports working for the ACGME and royalties for a textbook on assessment from Mosby-Elsevier. No other financial disclosures were reported.