Observations: Milestones for Combined Training Programs—Innovation or Burden?

Abstract

The Accreditation Council for Graduate Medical Education has adopted strategic priorities to (a) foster innovation and improvement in the learning environment; (b) increase the accreditation emphasis on educational outcomes; (c) increase efficiency and reduce burden in accreditation; and (d) improve communication and collaboration with key external stakeholders.”1 The Milestone Project is intended to advance these priorities.2 We suggest that b and d are true, but perhaps a and c are false, at least for combined training programs. The recent adaption of the Milestones shows great promise for thoughtful, quality evaluation of residents across all disciplines. The emphasis on the gradual increase in autonomy and outcome-driven skills is a fundamental shift toward the authentic evaluation of trainees. The Milestones also strike a balance between simple Likert scores and narrative-based evaluations, and Milestones also addresses a fundamental question: Can our trainees function independently? To date, there are 20 combined specialties, representing 187 programs and nearly 2000 residents.3 The largest of these programs are the combined internal medicine-pediatrics programs with 80 programs and more than 1400 trainees (table).3 TABLE ACGME Accredited Combined Specialty Residency Programsa Because the 6 core competencies are the same across specialties, the Milestones echo similar themes. However, the uniqueness of specific Milestones poses challenges for combined training programs. Simply stated, the challenge for combined training programs is how can we accurately, authentically measure these Milestones without the checklists becoming another empty Likert-scale exercise? Does the volume of distinct and nonparallel Milestones, each with well-crafted goals, cause the overall assessment to become too complex? If the aim of the Milestones is to contribute to better assessment, does their rigid language, sheer number, and misalignment pose an administrative burden on combined programs that may stifle innovation? Thoughtful Clinical Competency Committees likely will find their way through the Milestones, and the administrative burden may perhaps decrease with time, as the specifics will become second nature to residency program leaders. However, we are concerned that the demand of the Milestones on combined programs may be a more convoluted tracking standard. Authentic evaluation remains elusive, and yet, there is no substitute for direct, immediate, ongoing feedback and reflection from a supervisor to a trainee. This entails sustained commitment from the supervisor, trainee, and training program. The Milestones get us part of the way. As we move forward with their use, we must be careful not to let complexity get in the way.