The American Board of Medical Specialties (ABMS) and the Accreditation Council on Graduate Medical Education (ACGME) have established six core areas in which competency is expected by all physicians:
- Patient care and procedural skills
- Medical knowledge
- Practice-based learning and improvement
- Interpersonal and communication skills
- Systems-based practice
Residency programs are required to integrate learning and assessment of these six competencies throughout the process of preparing trainees for initial certification.
To enable training programs to more effectively evaluate performance in these six core competency areas, milestones related to each residency competency have been developed. Similar to developmental milestones used to evaluate normal development in childhood, training milestones in medicine are developmental outcomes involving acquisition of specific knowledge, skills, and attitudes, and the ability to apply them to the care of patients. These milestones provide a “roadmap” to training that can be followed by residents and faculty. They can be measured across training and it is expected that progression to more advanced milestones may vary by competency and learner, but that a resident must be considered prepared for unsupervised practice in each competency by the end of training.
Training milestones are specialty-specific; in internal medicine, the 6 competency areas are further defined by 22 subcompetencies (5 for patient care, 2 for medical knowledge, 4 for systems-based practice, 4 for practice-based learning and improvement, 4 for professionalism, and 3 for interpersonal and communication skills). Each subcompetency contains narratives (i.e. milestones) describing the performance associated with a specific level of acquisition of competence in that area that are used to place trainees in one of five categories for that domain. These categories are: “critical deficiency,” “behaviors of an early learner,” “behaviors of a resident who is advancing,” “ready for unsupervised practice,” or “aspirational.”
These are examples of subcompetency milestones for patient care and practice based learning and improvement:
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Resident milestone performance is assessed by residency program directors in conjunction with a clinical competency committee made up of 3 or more teaching faculty from the training program. Residency programs may use a variety of sources of evaluation data to assess milestone progress, including end-of-rotation evaluations, peer, staff and patient evaluations, mini-clinical evaluation exercises (mini-CEX) results, internal medicine in-service training examination scores, performance on objective structured clinical examinations (OSCEs), and other forms of performance competency evaluation. This information is synthesized by the program director and clinical competency committee into milestone ratings. The milestones provide residents and residency programs with an indicator of what skills and abilities a trainee possesses at a particular stage of training and indicate areas requiring further growth. This information also provides residency programs with information to make sure their curriculum is effectively structured for trainees to achieve competency in each of the required areas.
Residency programs are required to report milestone data for each trainee each year to the ACGME and American Board of Internal Medicine (ABIM). Promotion decisions are usually made by the program director in conjunction with the clinical competency committee. At the end of training, the program director must attest that the trainee has been assessed to be competent for unsupervised medical practice in all six core competency areas in order to be eligible for initial board certification.
You may also hear the term "entrustable professional activities (EPAs)" during your training. EPAs are descriptions of work-based activities that can serve as a meaningful point of assessment. Examples of EPAs include things such as performing an effective patient care hand-off or breaking bad news to a patient – activities that must be performed well to provide optimal medical care. Milestones provide granular descriptions of the knowledge, skills, and attitudes or behaviors that define the content of the six core competencies, whereas EPAs provide a means of assessing the effectiveness of their application to real world tasks. EPAs may be defined and developed by individual training programs and used for assessment during training and are often linked to increased autonomy and responsibility. However, they are not currently a part of evaluation for candidacy for initial board certification.