Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training

Journal of graduate medical education 09/2009; 1(1):5-20. DOI: 10.4300/01.01.0003
Source: PubMed


The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.
In November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency.
The task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the "competency" level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones.
The milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the profession's expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training.

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Available from: Eva M Aagaard
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    • "Now expand that constraint as one considers the use of milestones. Currently in Internal Medicine there are about 110 sub-competencies and milestones, in General Surgery, 80, and even in clerkships (where COREEPAs are rapidly approaching) there are more than 100 objectives per clerkship (Green et al. 2009; ACGME and The American Board of Surgery 2014;Klamen 2015). If the same percentage of actual observation holds (and one would certainly not expect that number to rise), this leaves 23, 17, and 21 þ components observed respectively, with the rest left unseen. "
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    ABSTRACT: Background: The idea of competency-based education sounds great on paper. Who wouldn't argue for a standardized set of performance-based assessments to assure competency in graduating students and residents? Even so, conceptual concerns have already been raised about this new system and there is yet no evidence to refute their veracity. Aims: We argue that practical concerns deserve equal consideration, and present evidence strongly suggesting these concerns should be taken seriously. Method: Specifically, we share two historical examples that illustrate what happened in two disparate contexts (K-12 education and the Department of Defense [DOD]) when competency (or outcomes-based) assessment frameworks were implemented. We then examine how observation and assessment of clinical performance stands currently in medical schools and residencies, since these methodologies will be challenged to a greater degree by expansive lists of competencies and milestones. Results/conclusions: We conclude with suggestions as to a way forward, because clearly the assessment of competency and the ability to guarantee that graduates are ready for medical careers is of utmost importance. Hopefully the headlong rush to competencies, milestones, and core entrustable professional activities can be tempered before even more time, effort, frustration and resources are invested in an endeavor which history suggests will collapse under its own weight.
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    • "A supervisor who can identify an appropriate learning task useful for patient care and provide relevant guidance can set the stage for skill development and eventually entrustment . Defined competencies and milestones can guide developmentally sequenced learning activities and assessments (Carraccio et al. 2002; Green et al. 2009) (Table 2). "
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    • "These resources do not specifically address communication with low HL patients. The ACGME has recently developed milestones for each of the competencies, including interpersonal and communication skills, but there are no milestones that specifically address communication with low HL patients (16). Programs that teach HL are appropriately focusing on communication skills found to be effective for low HL patients such as teach-back technique and using plain language (17). "
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