Milestone Myths and Misperceptions

Abstract

I n 1999 the Accreditation Council for Graduate Medical Education (ACGME) introduced 6 clinical competen-cies. 1 The longitudinal integration of these competencies into educational curricula and assessment of residents and fellows was intended to also generate outcomes assess-ments–based information on the educational effectiveness of training programs. In 2008, to further this process, ACGME Chief Executive Officer Thomas J. Nasca, MD, announced his vision for ''The Next Step in the Outcomes-Based Accreditation Project,'' 2 which became the Next Accreditation System (NAS). This vision was notable for 2 elements: development of specialty-specific, competency-based Milestones, along with design and implementation of Milestone assessment tools. The ultimate goal was to further transform graduate medical education from a process focus to an outcomes-based focus. In July 2013, 7 specialties that had volunteered to be early adopters of the NAS began their journey down this exciting and relatively uncharted path. 3 As a program director and member of the committee who created the Emergency Medicine Milestones, I have been struck by the incredible diversity of approaches during the Milestone rollout process. 4,5 Given this diversity, inevitably some applications of the Milestone framework may not result in the lofty aspirational goals that we hoped for. The Milestones, along with other elements of the NAS, are intended to promote program improvements via self-study driven by objective data. The Next Accreditation System emphasizes trainee assessment based on observable behav-iors, using stable, reproducible methods that eliminate that old educational saw, ''I know it when I see it.'' The community designing the Milestones aimed to make the assessment processes transparent and to stimulate creativity in the graduate medical education community with this paradigm shift. As the Milestones are beginning to be used, there are some misperceptions about the Milestones and misinterpretations in how they should be used (B O X). This perspective seeks to offer added clarity and address these misperceptions.