Using a Milestone Framework for Assessing Resident, Fellow, and Faculty Competence in Diversity, Equity, and Inclusion.

Abstract

Graduating residents and fellows who can competently provide equitable and inclusive care to a diverse patient population requires data to monitor progress and outcomes. This data must be continuously gathered and used to guide improvements at the individual program level and at the sponsoring institution level for trainee and faculty growth and development. Recognizing the need for data, the Accreditation Council for Graduate Medical Education (ACGME) updated its 2021 annual Resident/Fellow and Faculty Surveys to include items related to equity and inclusion. Yet, accessible data on the structural competency level of our residents and faculty specific to the areas of health equity, social responsibility, diversity, inclusion, and social determinants of health is limited.1Our aim was to develop and implement a quick, evidence-based, structural competency tool to monitor trainee and faculty proficiency over time. A literature review was completed to identify key competency elements. To facilitate implementation, we framed our assessment to parallel the structure and format of the ACGME's core competency milestone model. Literature-identified elements were plotted in each of the core competency domains with progression delineated across 5 levels resulting in a comprehensive 8-page milestone document. The milestone was then iteratively revised by multiple stakeholders (experts in diversity, equity, and inclusion, ethics, and medical education; faculty; learners; program directors) to create an annotated and referenced 2-page master milestone and an abbreviated milestone with domain threads across levels (eg, Medical Knowledge) for inclusion within each graduate medical education (GME) program's required milestone assessment form and for faculty self-assessment. For example, an element in the domain of Patient Care level 3 (Identifies and incorporates mitigation strategies to address structural risks in patient care) progresses to level 4 (Develops and collaborates with patient on plan of care cognizant of patient's intersectionalites and its influences on their health care values, decisions…). In the Professionalism domain, level 3 (Reconciles personal beliefs and identities with professional role; develops strategies to mitigate own implicit biases; recognizes the contribution of bias to iatrogenic risk and health disparities) progresses to level 4 (Speaks up in the moment [allyship]; utilizes incident reporting mechanism to address microaggressions and/or lateral workplace violence).The milestone was approved by the Graduate Medical Education Committee (GMEC) for inclusion as a required formative trainee assessment in every program beginning in January 2021 and as a request for faculty to complete as a needs assessment. Data are not used for trainee progress (Clinical Competency Committee reviews) or annual faculty performance reviews. Trainee milestone data across programs revealed a consistent progression in the institutional average competence by year of training from 3.1 (postgraduate year [PGY]-1) to 4.4 (PGY-6). The same progression held within each residency and fellowship program. Faculty self-assessment (N>100) revealed that, on average, greater than 50% of the faculty perceived themselves to be at level 4 or higher: range between domains of 53%–79% at or above level 3 by competency domain with SD 1.1 to 1.7. Programs utilize the data as part of their annual program evaluations outlining measurable action steps. At the GMEC level, the data guide GME-wide diversity, equity, and inclusion educational sessions for trainees and faculty.This structural milestone innovation meets our need for data to monitor our trainees' and faculty's competence to guide ongoing program improvements. Formatted like existing ACGME Milestones, implementation within existing trainee competency assessment systems and/or as a faculty self-assessment is seamless, enhancing its utility, feasibility, and transferability. That said, we recognize that milestones are not static; the specific domain inclusions will need to evolve as we do on our equity journey.