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.

Examples of Level 3 milestones within the Practice-based Learning and Improvement core competency:

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.


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”5


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.5 The ACGME made the residency requirements more formal, but there was a perceived decrease in innovation and an increase in administrative burden.5 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.5


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”.5 These attributes overlap broadly with clinical informatics, which includes patient engagement in electronic health records, clinical decision support and data retrieval.6

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 competencies7, 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.8

• Hersh et al mapped clinical informatics competencies to the general competencies for an undergraduate medical education curriculum.9


Related topics

Quality Informatics

Evidence-based medicine


Submitted by Sarah Gebauer, MD

1. Accreditation Council for Graduate Medical Education. (Accessed April 18, 2015, at https://http://www.acgme.org/acgmeweb/Portals/0/MilestonesFAQ.pdf.) 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://http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf.) 3. The Anesthesiology Milestone Project. The Accreditation Council for Graduate Medical Education and The American Board of Anesthesiology, 2013. (Accessed April 18, 2015, at http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/AnesthesiologyMilestones.pdf.) 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://http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf.) 5. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system--rationale and benefits. N Engl J Med 2012;366:1051-6. 6. Clinical Informatics. (Accessed April 21, 2015, at https://http://www.amia.org/applications-informatics/clinical-informatics.) 7. 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. 8. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310:2249-50. 9. 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.