Graduate Medical Education Milestones

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Graduate medical education (residency and fellowship) is increasingly focusing on systems- and practice-based improvement as part of training a physician workforce that is comfortable with these concepts. The primary method of assessment currently is milestones.

What are milestones?

Milestones are “competency-based developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents/fellows from the beginning of their education through graduation to the unsupervised practice of their specialties”1. They were developed by the American Council on Graduate Medical Education (ACGME) and incorporate six core competencies:

• patient care

• medical knowledge

• systems-based practice

• practice-based learning and improvement

• professionalism

• interpersonal and communications skills

Specialty specificity

Each specialty has worked with the ACGME to develop specific milestones for each area of competency, described in 4-5 levels from novice (Level 1) to expert (Level 5).1,2 These milestones vary widely in specifics, but are all described in the same format and according to the six core competencies.

For example, a Family Medicine resident at Level 4 competency for Patient Care “integrates disease prevention and health promotion seamlessly in the ongoing care of all patients”2 while an anesthesiology resident at Level 4 competency for Patient Care “conducts complex anesthetics with conditional independence; may supervise others in the management of complex clinical problems”3. Both of these competencies are crucial to their respective fields, but a family medicine resident would not be expected to conduct a complex anesthetic, and an anesthesiology resident would not be expected to integrate disease prevention into the care of all patients. However, they are both reflect a level of sophistication in medical practice within their respective fields that experts believe would be sufficient for a graduating resident.

Some of the milestones, particularly in competencies such as Practice-based Learning and Improvement and Systems-based Practice, describe similar objectives in slightly different language.

For example, below are Level 3 milestones within the Practice-based Learning and Improvement core competency in three distinct fields:

Anesthesiology: “Identifies patient safety issues within one’s practice, and participates in quality improvement plans to address them”3

Family medicine: “Uses a systematic improvement method (e.g., Plan-Do-Study-Act (PDSA) cycle) to address an identified area of improvement”2

Psychiatry: “Involves appropriate stakeholders in design of a QI project”.4

Goals of the milestones

The goals of the milestones are primarily to aid in curriculum development, program accreditation, and resident learning1.

Resident assessment with milestones

In general, level 4 is meant to be the goal for graduating residents, though a resident does not have to reach a specific level in order to graduate. Residents are evaluated on at least a yearly basis, and the system is intended to help identify learning opportunities earlier in the resident’s career. Because the focus of milestones is on learner outcomes, the historically very tight time constraints of a residency program (generally 3-5 years depending on the specialty) or fellowship (generally 1-3 years depending on the subspecialty) could be erased. This means exceptional residents could theoretically graduate in less than the anticipated time, and that others may need to stay in residency for additional time to achieve the milestones.5

Milestones and the Next Accreditation System

The Next Accreditation System (NAS) is a system for the ACGME to ensure high quality of residency programs. Its goal is in part to “accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes”6

History of milestones

The ACGME was created in 1981 in response to more formal sub-specialization and a perceived lack of consistency in quality of residency education.6 The ACGME made the residency requirements more formal, but there was a perceived decrease in innovation and an increase in administrative burden.6 The six clinical competencies were introduced in 1999. Milestones data was first collected in 2012, with seven specialties including internal medicine and pediatrics being early adopters.6

Controversies of the milestones

Some have argued that the focus on outcomes fails to capture measures that are crucial to a good physician but more difficult to measure, such as “situational awareness, empathy, leadership, and resource management”5.

Others have argued that because the milestones rely on human raters that often use subjective or selective information to score the residents, “the meanings of the ratings that are combined into an overall summative judgment are highly variable”7. Some have questioned whether attending physicians’ supervision of residents is adequate to develop a well-informed opinion about a resident’s competency level7.

One group attempted to identify validated evaluation tools for the competencies, but determined “the peer-reviewed literature provides no evidence that current measurement tools can assess the competencies independently of one another”8.

Clinical informatics and milestones

The ACGME states that “patients, payers, and the public demand information-technology literacy, sensitivity to cost-effectiveness, the ability to involve patients in their own care, and the use of health information technology to improve care for individuals and populations”.6 These attributes overlap broadly with clinical informatics, which includes patient engagement in electronic health records, clinical decision support and data retrieval.9

Clinical informatics impacts several of the areas of competencies included in the milestones. The most notable overlap between clinical informatics and graduate medical education is in the areas of systems-based practice and practice-based learning and improvement, as well as some aspects of professionalism. Several examples of clinical informatics-associated milestones from disparate specialties are provided below.

Journal articles on clinical informatics and milestones

• Tierney et al identified issues with EHRs related to the core competencies10, including the use of clinical decision support (CDS), automation bias, data gathering and presentation, and computer-provider interactions.

• Pageler et al suggested additions to the core competencies that incorporate EMR-related learning opportunities, such as CDS tailored to trainee knowledge gaps, and trainee-specific clinical outcome reports.11

• Hersh et al mapped clinical informatics competencies to the general competencies for an undergraduate medical education curriculum.12

Related topics

Quality Informatics


1. Accreditation Council for Graduate Medical Education. (Accessed April 18, 2015, at https://

2. The Family Medicine Milestone Project. The Accreditation Council for Graduate Medical Education and The American Board of Family Medicine. (Accessed April 18, 2015, at https://

3. The Anesthesiology Milestone Project. The Accreditation Council for Graduate Medical Education and The American Board of Anesthesiology, 2013. (Accessed April 18, 2015, at

4. The Psychiatry Milestones Project. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, 2013. (Accessed April 18, 2015, at https://

5. Ebert TJ, Fox CA. Competency-based education in anesthesiology: history and challenges. Anesthesiology 2014;120:24-31.

6. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system--rationale and benefits. N Engl J Med 2012;366:1051-6.

7. Williams RG, Dunnington GL, Mellinger JD, Klamen DL. Placing Constraints on the Use of the ACGME Milestones: A Commentary on the Limitations of Global Performance Ratings. Acad Med 2015;90:404-7.

8. Lurie SJ, Mooney CJ, Lyness JM. Measurement of the general competencies of the accreditation council for graduate medical education: a systematic review. Acad Med 2009;84:301-9.

9. Clinical Informatics. (Accessed April 21, 2015, at https://

10. Tierney MJ, Pageler NM, Kahana M, Pantaleoni JL, Longhurst CA. Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions. Acad Med 2013;88:748-52.

11. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310:2249-50.

12. Hersh WR, Gorman PN, Biagioli FE, Mohan V, Gold JA, Mejicano GC. Beyond information retrieval and electronic health record use: competencies in clinical informatics for medical education. Adv Med Educ Pract 2014;5:205-12.

Submitted by Sarah Gebauer