Development of the Educational Milestones for Surgery

Abstract

A working group (B O X) to develop educational Milestones for surgery was first convened in 2009. Under the leadership of Richard H. Bell Jr, MD, American Board of Surgery (ABS), the group consisted of 12 members representing ABS, the Accreditation Council for Graduate Medical Education (ACGME), the Residency Review Committee for Surgery (RRC-Surgery), and the Association for Program Directors in Surgery (APDS). The group included 1 resident member and an expert in surgical evaluation and performance assessment. In 2011, 5 new members were added, including 2 new members each from the RRC-Surgery and the APDS and a new chair from the ABS, Thomas H. Cogbill, MD. The working group began the development of the Milestones by reviewing the Dreyfus model of professional development (from novice to expert), 1 along with perspectives from the literature on expertise, 2 and contemporary methods of evaluation for surgeons in training. 3-5 The working group then undertook a multistep project to define the primary domains of practice in which surgical trainees needed to develop proficiency. Eight distinct domains of surgical practice were selected: (1) care for diseases and conditions; (2) coordination of care; (3) performance of operations and procedures; (4) self-directed learning; (5) teaching; (6) improvement of care; (7) maintenance of physical and emotional health; and (8) performance of administrative tasks. These domains provided a framework for identifying Milestones integrally related to residents' learning and performance of patient care and related professional responsibilities. The group identified the ACGME competencies that were most relevant to each domain and then developed Milestones for each of these competency-domain pairs. The group drew from the widely used SCORE curriculum to describe advancing expertise in patient care and technical skills. 6 For example, early levels of patient care for the domain ''Performance of Operations and Procedures'' describe the expectation that residents perform steps in some essential/common operations identified in the SCORE curriculum, whereas higher levels describe the expectation that residents perform all essential operations (without the need for direct supervision) and have significant experience with complex operations in the SCORE curriculum. The working group also referenced the 2011 report from the ACGME expert panel that focused on Milestone development for professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice to modify draft Milestones. A principle that guided the group was to make Milestones as succinct as possible, while ensuring that essential skills, knowledge, and behaviors for unsupervised surgical practice were represented. With this in mind, the working group conducted numerous reviews of progressive iterations of the Milestones and made revisions to reduce redundancy and fine tune the Milestones. Organization of the Surgery Milestones The final product consisted of 16 subcompetencies that were mapped to both an ACGME competency and a single domain of surgical practice. Sets of descriptors were composed for definitions of critical deficiency and a ''Milestone set'' consisting of 4 levels of performance. These descriptors were designed to discriminate between each of the levels of performance. The 16 sets of Surgery Milestones map to the ACGME competencies as follows: 3 Milestones for patient care; 2 for medical knowledge; 2 for systems-based practice; 3 for practice-based learning and improvement; 3 for professionalism; and 3 for interper