74. MILESTONES ACHIEVEMENT FROM RESIDENCY TO FELLOWSHIP: A CONTINUUM?

Abstract

Background In 2013, the ACGME implemented the Milestones as a competency-based evaluation framework, spanning the continuum from novice to expert. Some subcompetencies from residency programs were adopted into subspecialty subcompetencies with the same 5-point scores. ACGME Milestones reports indicate lower achievement in identical subcompetencies for first year Pediatric Emergency Medicine (PEM) fellows compared with graduating pediatric residents. While differences between residency and fellowship programs exist, it is unclear why demonstrated skills would be “lost” by residents transitioning to PEM fellowship as suggested by lower milestones scores. Aim To investigate the trajectory of milestone scores from residency to PEM fellowship. Methods We completed a multicenter retrospective cohort study of a national sample of PEM fellows. Participating programs submitted de-identified Milestones data for PEM fellows (2015-2018). Of 23 PEM subcompetencies, 10 were adopted from pediatric and 7 from EM residency subcompetencies. We compared first year PEM fellow performance for these 17 subcompetencies to end-of-residency performance, using Wilcoxon signed rank tests to evaluate the difference in fellows paired scores. A 1-point decline in milestone score was deemed a priori to be clinically significant. Results We collected data for 639 PEM fellows from 48 fellowships. End-of-residency scores were available for 218 fellows from 42 programs. Most (210/218, 96%) completed pediatric residencies; 8 (4%) completed EM training. Declines in median milestones scores between end-of-residency and first year of PEM fellowship were observed for all fellows. These declines were statistically significant for pediatric-trained fellows; clinically significant declines were seen in two subcompetencies (Table 1). Conclusions Our study found significant declines across adopted pediatric subcompetencies for pediatric residency graduates assessed early in their PEM fellowships. It is unclear whether this observed decline in achievement represents a true loss of skills, or a reset of faculty expectations and variance of Milestones interpretation by fellowships. Future studies are warranted to examine whether Milestones accurately assess trainee development across the continuum, or if they are applied differently as physicians transition from residency to subspecialty training.