Milestone Data Research Articles

Longitudinal Reliability of Milestones Learning Trajectories during Anesthesiology Residency.

Longitudinal Milestones data reported to the Accreditation Council for Graduate Medical Education (ACGME) provide a structured framework for assessing the developmental progression of residents in key competencies and subcompetencies. This study aims to investigate the previously underexplored longitudinal reliability of Milestones data, with the goal of identifying patterns in learning trajectories that can inform targeted interventions for residents and programs. We conducted a retrospective cohort study with national anesthesiology Milestones data collected from 2014 to 2020. Mixed-effects growth curve models were fit to model residents' growth trajectories. Longitudinal reliability was assessed using the indices of growth rate reliability (GRR) and growth curve reliability (GCR). We also examined variance components attributable to the factors at both the learner and program levels. Latent class growth analyses (LCGA) were performed to identify latent groups of learners with different learning trajectories. The study included a total of 682,475 ratings for 4976 learners in 140 programs. Growth curve model results indicated that the mean baseline Milestone rating across the 25 subcompetencies was 2.05 (95% CI: 1.96-2.14), with an average increase of 0.49 (95% CI: 0.48-0.51) units per reporting period. The GRR (mean ± SD, 0.58 ± 0.03) suggested a moderate capability of anesthesiology Milestones to detect individual differences in the growth of latent competency. GCR estimates (mean ± SD, 0.76 ± 0.02) suggested acceptable overall reliability of Milestones across all the six assessment points. Significant variability was observed at both the program and learner levels (P < 0.001). LCGA identified 3-4 latent groups of learners with distinct learning trajectories across the 25 subcompetencies. Our study indicated that the anesthesiology Milestones provides moderately reliable information for tracking individual progress over time. The findings underscore the importance of using a multi-faceted approach to assessment and providing individualized learning plans to support resident development.

Delineating Neurosurgery Resident Development: Insights from a 10-Year National Accreditation Council for Graduate Medical Education Milestones and Learning Trajectories.

The Accreditation Council for Graduate Medical Education Milestones assessment system provides a structured framework for evaluating the developmental progression of neurosurgery residents. Understanding the variability in learning trajectories and identifying critical intervention points are essential for refining educational strategies and enhancing training outcomes. In this article, we aim to identify learning trajectories of neurosurgery residents and pinpoint pivotal junctures for potential interventions to aid residents struggling to meet expected competency levels. We analyzed Accreditation Council for Graduate Medical Education Milestones data from 3541 neurosurgery residents across 124 programs from 2013-2014 to 2022-2023. We examined the reliability of Milestone assessments across programs and addressed potential biases because of program-level differences. Through cluster analysis, we identified distinct learning trajectories, focusing on competency-specific developments and crucial intervention points based on divergences in trajectory. Our analysis revealed 5 distinct learning trajectories among neurosurgery residents, highlighting diverse developmental pathways. Cluster 1 (n = 1,719, 48.5%) and Cluster 2 (n = 341, 9.6%) demonstrated initial foundational competencies but varied in progression, with Cluster 2 failing to meet the threshold for independent practice by postgraduate year 7 consistently. Cluster 3 (n = 459, 13%), starting with the lowest initial competency levels, surpassed independence thresholds, illustrating the potential for significant growth regardless of initial competency levels. Cluster 4 (n = 520, 14.7%) and Cluster 5 (n = 502, 14.2%) exhibited accelerated competency development, achieving early readiness for independent practice. We found no significant association between cluster membership and program characteristics, suggesting that the trajectories reflect individual variations rather than programmatic differences. Our findings highlight the need for educational strategies tailored to residents' unique development paths to support the achievement of competency thresholds. While the data suggest potential benefits of adaptive learning, further exploration is required to confirm its impact on educational outcomes.

Analisis Klasterisasi Patok Jalan Berbasis Geospasial Menggunakan K-Means dan Evaluasi Davies-Bouldin

Geographic Information System (GIS) has become a very important tool for spatial analysis and decision making in various fields. In this paper, the analysis process of grouping Kilometer Hectometer (KM/HM) road milestones use the K-Means method in the context of GIS. The KM/HM road milestones are road equipment made of concrete or signboards equipped with texts containing information about the distance and the name of the city to be traveled by road users. The length of the road that has such a long distance will make it difficult to maintain and to manage the road milestones that are scattered throughout the road. Currently, the process of mapping the location of the road milestones is still being carried out using the conventional method, in which the survey officer records the data on paper and measures it with the vehicle's odometer. However, this method often causes data loss, errors in determining the location, and lacks photographic evidence as a reference for assessing the condition of the road milestones. The role of GIS for survey officers is to map the road milestones and to visualize the road milestone data. The main objective is to gain meaningful insights from the spatial distribution of these road milestones, which will assist in better navigation and infrastructure planning. The K-Means method separates clusters from KM/HM road milestones which are identified based on geographical proximity. To assess the quality of these clusters, the evaluation is conducted using the Davies-Bouldin index (DBI) which provides a quantitative measure of inter-group similarity and within-group dissimilarity. For officers, it can be useful to find location points for the road milestones that have high damage conditions to prioritize to be repaired first. Based on the test results using DBI, it produces a value close to zero, which is equal to 0.1656, indicating that the clusters formed have very good quality.

Predicting Performance in the Physical Medicine and Rehabilitation Part II Certification Oral Examination Based On Milestone Ratings.

The Accreditation Council for Graduate Medical Education (ACGME) introduced the Milestones to document learner development within a competency-based framework. On the other hand, board certifying examinations serve as a summative evaluation of a learner's readiness for independent medical practice. Scores in Part I of the American Board of Physical Medicine and Rehabilitation (ABPMR) examination, which measures medical knowledge, has been shown to correlate only with Milestones ratings in medical knowledge. We hypothesized that combined ratings of various Milestone competencies can predict subsequent performance in related ABPMR Part II certifying examination domains. Milestones data and ABPMR Part II examination scores of trainees in 3-yr PM&R residency programs in the United States from academic years (AY) 2014-2016 who sat for the ABPMR Parts I and II Examinations, immediately after completion of training, were reviewed. Regression analysis showed that Milestone sub-competencies, alone or in combination, did not correlate with Part II domain scaled scores. Medical Knowledge was the only Milestone sub-competency that was correlated with performance in the ABPMR Part I certifying examination. This current study found that no similar association exists between any of the Milestones Competencies and the ABPMR Part II certifying examination, suggesting that the two assessment tools measure different attributes.

Are They Prepared? Comparing Intern Milestone Performance of Accelerated 3-Year and 4-Year Medical Graduates.

Accelerated 3-year programs (A3YPs) at medical schools were developed to address student debt and mitigate workforce shortage issues. This study investigated whether medical school length (3 vs 4 years) was associated with early residency performance. The primary research question was as follows: Are the Accreditation Council for Graduate Medical Education Milestones (MS) attained by A3YP graduates comparable to graduates of traditional 4-year programs (T4YPs) at 6 and 12 months into internship? The MS data from students entering U.S. medical schools in 2021 and 2022 from the 6 largest specialties were used: emergency medicine, family medicine, internal medicine, general surgery, psychiatry, and pediatrics. Three-year and 4-year graduates were matched for analysis (2,899 matched learners: 182 in A3YPs and 2,717 in T4YPs). The study used a noninferiority study design to examine data trends between the study cohort (A3YP) and control cohort (T4YP). To account for medical school and residency program effects, the authors used cross-classified random-effects regression to account for clustering and estimate group differences. The mean Harmonized MS ratings for the midyear and end-year reporting periods showed no significant differences between the A3YP and T4YP groups (mean [SE] cross-classified coefficient = 0.01 [0.02], P = .77). Mean MS ratings across internal medicine MS for the midyear and end-year reporting periods showed no significant differences between the A3YP and T4YP groups (mean [SE] cross-classified coefficient = -0.03 [0.03], P = .31). Similarly, for family medicine, there were no statistically significant differences between the A3YP and T4YP groups (mean [SE] cross-classified coefficient = 0.01 [0.02], P = .96). For the specialties studied, there were no significant differences in MS performance between 3-year and 4-year graduates at 6 and 12 months into internship. These results support comparable efficacy of A3YPs in preparing medical students for residency.

Pediatric residency milestone performance is not predicted by the United States Medical Licensing Examination Step 2 Clinical Knowledge.

This study aims to show whether correlation exists between pediatric residency applicants' quantitative scores on the United States Medical Licensing Exam Step 2 Clinical Knowledge examination and their subsequent performance in residency training based on the Accreditation Council for Graduate Medical Education Milestones, which are competency-based assessments that aim to determine residents' ability to work unsupervised after postgraduate training. No previous literature has correlated Step 2 Clinical Knowledge scores with pediatric residency performance assessed by Milestones. In this retrospective cohort study, the United States Medical Licensing Exam Step 2 Clinical Knowledge Scores and Milestones data were collected from all 188 residents enrolled in a single categorical pediatric residency program from 2012 - 2017. Pearson correlation coefficients were calculated amongst available test and milestone data points to determine correlation between test scores and clinical performance. Using Pearson correlation coefficients, no significant correlation was found between quantitative scores on the Step 2 Clinical Knowledge exam and average Milestones ratings (r = -0.1 for post-graduate year 1 residents and r = 0.25 for post-graduate year 3 residents). These results demonstrate that Step 2 scores have no correlation to success in residency training as measured by progression along competency-based Milestones. This information should limit the importance residency programs place on quantitative Step 2 scores in their ranking of residency applicants. Future studies should include multiple residency programs across multiple specialties to help make these findings more generalizable.

Accreditation Council for Graduate Medical Education Milestone Training Ratings and Surgeons’ Early Outcomes

National data on the development of competence during training have been reported using the Accreditation Council for Graduate Medical Education (ACGME) Milestones system. It is now possible to consider longitudinal analyses that link Milestone ratings during training to patient outcomes data of recent graduates. To evaluate the association of in-training ACGME Milestone ratings in a surgical specialty with subsequent complication rates following a commonly performed operation, endovascular aortic aneurysm repair (EVAR). This study of patient outcomes followed EVAR in the Vascular Quality Initiative (VQI) registry (4213 admissions from 208 hospitals treated by 327 surgeons). All surgeons included in this study graduated from ACGME-accredited training programs from 2015 through 2019 and had Milestone ratings 6 months prior to graduation. Data were analyzed from December 1, 2021, through September 15, 2023. Because Milestone ratings can vary with program, they were corrected for program effect using a deviation score from the program mean. Milestone ratings assigned to individual trainees 6 months prior to graduation, based on judgments of surgical competence. Surgical complications following EVAR for patients treated by recent graduates during the index hospitalization, obtained using the nationwide Society for Vascular Surgery Patient Safety Organization's VQI registry, which includes 929 participating centers in 49 US states. The study included outcomes for 4213 patients (mean [SD] age, 73.25 [8.74] years; 3379 male participants [80.2%]). Postoperative complications included 9.5% major (400 of 4213 cases) and 30.2% minor (1274 of 4213 cases) complications. After adjusting for patient risk factors and site of training, a significant association was identified between individual Milestone ratings of surgical trainees and major complications in early surgical practice in programs with lower mean Milestone ratings (odds ratio, 0.50; 95% CI; 0.27-0.95). In this study, Milestone assessments of surgical trainees were associated with subsequent clinical outcomes in their early career. Although these findings represent one surgical specialty, they suggest Milestone ratings can be used in any specialty to identify trainees at risk for future adverse patient outcomes when applying the same theory and methodology. Milestones data should inform data-driven educational interventions and trainee remediation to optimize future patient outcomes.

Evaluation of Family Medicine Residency Programs for Diversity, Equity, and Inclusion Milestones.

In 2020, the Association of Family Medicine Residency Directors (AFMRD) Diversity and Health Equity (DHE) Task Force developed and piloted a framework to measure diversity, equity, and inclusion (DEI) initiatives in medical residencies across five domains: curriculum, evaluation, institution, resident pathway, and faculty pathway. The objectives were (1) to measure DEI initiatives across multiple domains in family medicine residencies using the DEI milestones and (2) to obtain current national baseline data providing criteria against which to measure effectiveness of initiatives and create tailored benchmarks. We developed a cross-sectional survey of 12 quantitative residency characteristic items and the five DEI milestone ratings, and distributed the survey to program directors of family medicine residencies accredited by the Accreditation Council for Graduate Medical Education in the spring of 2022. We generated descriptive statistics, including item frequencies and cross-tabulations, and completed subgroup comparisons with analysis of variance. We collected aggregate milestone data for 194 family medicine residencies of 588 eligible programs (33% response rate). Respondents represented 48 states and US territories: 107 community-based, university-affiliated; 48 community-based; 34 university-based; and 5 military/other programs. Overall, the curriculum milestone was rated the highest (mean=2.54, SD=1.03), whereas the faculty pathway (mean=1.94, SD=1.04) and resident pathway (mean=2.02, SD=1.06) milestones were rated lowest. DEI milestone data may support residency programs as they assess their institution's developmental progress across five key domains. Additionally, aggregate data may shed light on collective strengths and areas for improvement.

Assessing the impact of adopting a competency-based medical education framework and ACGME-I accreditation on educational outcomes in a family medicine residency program in Abu Dhabi Emirate, United Arab Emirates.

Competency-Based Medical Education (CBME) is now mandated by many graduate and undergraduate accreditation standards. Evaluating CBME is essential for quantifying its impact, finding supporting evidence for the efforts invested in accreditation processes, and determining future steps. The Ambulatory Healthcare Services (AHS) family medicine residency program has been accredited by the Accreditation Council of Graduate Medical Education-International (ACGME-I) since 2013. This study aims to report the Abu Dhabi program's experience in implementing CBME and accreditation. Compare the two residents' cohorts' performance pre-and post-ACGME-I accreditation.Study the bi-annually reported milestones as a graduating residents' performance prognostic tool. All residents in the program from 2008 to 2019 were included. They are called Cohort one-the intake from 2008 to 2012, before the ACGME accreditation, and Cohort two-the intake from 2013 to 2019, after the ACGME accreditation, with the milestones used. The mandatory annual in-training exam was used as an indication of the change in competency between the two cohorts. Among Cohort two ACGME-I, the biannual milestones data were studied to find the correlation between residents' early and graduating milestones. A total of 112 residents were included: 36 in Cohort one and 76 in Cohort two. In Cohort one, before the ACGME accreditation, no significant associations were identified between residents' graduation in-training exam and their early performance indicators, while in Cohort two, there were significant correlations between almost all performance metrics. Early milestones are correlated with the graduation in-training exam score. Linear regression confirmed this relationship after controlling the residents' undergraduate Grade Point Average (GPA). Competency development continues to improve even after residents complete training at Post Graduate Year, PGY4, as residents' achievement in PGY5 continues to improve. Improved achievement of residents after the introduction of the ACGME-I accreditation is evident. Additionally, the correlation between the graduation in-training exam and graduation milestones, with earlier milestones, suggests a possible use of early milestones in predicting outcomes.

Pediatric residency milestone performance is not predicted by the United States Medical Licensing Examination Step 2 Clinical Knowledge

Objectives: This study aims to show whether correlation exists between pediatric residency applicants’ quantitative scores on the United States Medical Licensing Exam Step 2 Clinical Knowledge examination and their subsequent performance in residency training based on the Accreditation Council for Graduate Medical Education Milestones, which are competency-based assessments that aim to determine residents’ ability to work unsupervised after postgraduate training. No previous literature has correlated Step 2 Clinical Knowledge scores with pediatric residency performance assessed by Milestones. Methods: In this retrospective cohort study, the United States Medical Licensing Exam Step 2 Clinical Knowledge Scores and Milestones data were collected from all 188 residents enrolled in a single categorical pediatric residency program from 2012 - 2017. Pearson correlation coefficients were calculated amongst available test and milestone data points to determine correlation between test scores and clinical performance. Results: Using Pearson correlation coefficients, no significant correlation was found between quantitative scores on the Step 2 Clinical Knowledge exam and average Milestones ratings (r = -0.1 for post-graduate year 1 residents and r = 0.25 for post-graduate year 3 residents). Conclusions: These results demonstrate that Step 2 scores have no correlation to success in residency training as measured by progression along competency-based Milestones. This information should limit the importance residency programs place on quantitative Step 2 scores in their ranking of residency applicants. Future studies should include multiple residency programs across multiple specialties to help make these findings more generalizable.

Assessing the safety and activity of cabozantinib combined with lanreotide in gastroenteropancreatic and thoracic neuroendocrine tumors: rationale and protocol of the phase II LOLA trial

BackgroundWell-differentiated (WD) neuroendocrine tumors (NETs) are a group of rare neoplasms with limited therapeutic options. Cabozantinib is an inhibitor of multiple tyrosine kinases with a pivotal role in NET pathogenesis, including c-MET and Vascular Endothelial Growth Factor Receptor 2 (VEGFR2). LOLA is the first prospective phase II trial aiming to assess the safety and activity of cabozantinib combined with lanreotide in WD NETs of gastroenteropancreatic (GEP), thoracic and of unknown origin.MethodsThis is a multicenter, open-label, double-cohort, non comparative, non-randomized, three-stage phase II trial. Eligible patients have to meet the following inclusion criteria: diagnosis of advanced or metastatic, progressive, non-functioning WD thoracic NETs, GEP-NETs or NETs of unknown origin with Ki67 ≥ 10%; positive 68 Ga-PET uptake or somatostatin receptor 2 immunohistochemical (IHC) stain; maximum 1 prior systemic regimen for metastatic disease. Two cohorts will be considered: pNETs and carcinoids (typical or atypical lung and thymus NETs, gastro-intestinal NETs or NETs of unknown origin). In stage I, the primary objective is to find the optimal dose of cabozantinib in combination with lanreotide and to evaluate the safety of the combination (percentage of patients experiencing grade 3–5 toxicities according to NCI-CTCAE version 5.0). Starting dose of cabozantinib is 60 mg/day continuously, plus lanreotide 120 mg every 28 days. In stage II and III, co-primary endpoints are safety and overall response rate (ORR) according to RECIST version 1.1. The uninteresting antitumor activity is fixed in ORR ≤ 5%. Secondary endpoints are progression-free survival and overall survival. Exploratory objectives include the assessment of c-MET, AXL and VEGFR2 IHC expression, to identify predictive or prognostic tissue biomarkers. Enrolment started in July 2020, with an expected trial duration of 42 months comprehensive of accrual, treatment and follow-up. Considering a drop-out rate of 5%, the maximum number of enrolled patients will be 69.DiscussionSupported by a solid rationale, the trial has the potential to generate milestone data about the synergistic effects of cabozantinib plus lanreotide in a group of NET patients with relatively aggressive disease and limited therapeutic options.Trial registrationLOLA is registered at ClinicalTrials.gov (NCT04427787) and EudraCT (2019–004506-10).

Risk for Developmental Delay Among Infants Born During the COVID-19 Pandemic.

Attempts by governments around the world to mitigate the spread of COVID-19 have substantially altered the early rearing environment, raising concerns about potential negative consequences for babies born during this time. The objective of this study was to determine whether infants born during the COVID-19 pandemic were at greater risk of screening positive for developmental delay compared with infants born before the pandemic. Participants were from 2 longitudinal cohorts. The prepandemic cohort, Impact of Maternal and Paternal Postpartum Depression, recruited postpartum individuals in the period between 2015 and 2018. Infant development milestone data (Ages and Stages Questionnaire [ASQ-3]) were collected at 1-year postpartum (n = 2903), between 2016 and 2019. The pandemic cohort, Pregnancy during the Pandemic, recruited pregnant individuals between April 2020 and April 2021. Infant development milestone data (ASQ-3) were collected at 1-year postpartum (n = 3742), between May 2021 and December 2022. Sociodemographic information, pregnancy outcomes, and depression symptom data were also collected. In covariate-adjusted analyses, pandemic-born infants had lower mean scores and higher odds of screening positive for delay on the Communication, Gross Motor, and Personal-Social domains of the ASQ-3 compared with prepandemic infants. Sex differences showed that males and females screened "at risk" in different domains. Most pandemic-born infants display typical development, and differences between prepandemic and pandemic-born infants were small. Nevertheless, an increased risk for delayed development among pandemic-born infants suggests the need for ongoing monitoring to determine what, if any, resources and interventions are needed to support healthy child development.

New ACGME Clinician Educator Milestones as a Roadmap for Faculty Development: a Position Paper from the Society of General Internal Medicine Education Committee.

Traditionally, clinician educators are tasked with the responsibility of training future physician workforce. However, there is limited identification of skills required to fulfill this responsibility and a lack of consensus on effective faculty development for career growth as a clinician educator. The newly released Accreditation Council of Graduate Medical Education (ACGME) Clinician Educator (CE) Milestones framework outlines important skills for clinician educators and provides the opportunity to create robust faculty development. In this paper, members of the Society of General Internal Medicine Education Committee discuss the importance of these CE Milestones, outline the novel themes highlighted in the project, and provide recommendations for proper application on both the individual and institutional levels to optimize faculty development. The paper discusses strategies for how to apply the CE Milestones as a tool to create a culture of professional growth and self-directed learning. Using a reflective approach, CE faculty and mentors can identify areas of proficiency and opportunities for growth, thereby creating individualized professional development plans for career success. Institutions should use aggregate CE Milestones data as a needs assessment of their faculty "population" to create targeted faculty development. Most importantly, institutions should not use CE Milestones for high-stakes assessments but rather encourage reflection by CE faculty and create subsequent robust faculty development programs. The ACGME CE Milestones present an exciting opportunity and lay an important foundation for future CE faculty development.

Detecting residents at risk of attrition – A Singapore pathology residency's experience

The SingHealth Pathology Residency Program (SHPRP) is a 5-year postgraduate training program in Singapore. We face the problem of resident attrition, which has a significant impact on the individual, program and healthcare providers. Our residents are regularly evaluated, using in-house evaluations as well as assessments required in our partnership with the Accreditation Council for Graduate Medical Education International (ACGME-I). We hence sought to determine if these assessments were able to distinguish residents who would attrite from residents who would graduate successfully. Retrospective analysis of existing residency assessments was performed on all residents who have separated from SHPRP and compared with residents currently in senior residency or graduated from the program. Statistical analysis was performed on quantitative assessment methods of Resident In-Service Examination (RISE), 360-degree feedback, faculty assessment, Milestones and our own annual departmental mock examination. Word frequency analysis of narrative feedback from faculty assessment was used to generate themes.Since 2011, 10 out of 34 residents have separated from the program. RISE, Milestone data and the departmental mock examination showed statistical significance in discriminating residents at risk of attrition for specialty-related reasons from successful residents. Analysis of narrative feedback showed that successful residents performed better in areas of organization, preparation with clinical history, application of knowledge, interpersonal communication and achieving sustained progress. Existing assessment methods used in our pathology residency program are effective in detecting residents at risk of attrition. This also suggests applications in the way that we select, assess and teach residents.

A data-driven validation of mobile-based care (mCARE) project for children with ASD in LMICs

In this study, we have validated the aims of the NIH project mCARE (mobile-based care for monitoring the milestone and behavioral parameters for children with ASD) by data-driven techniques. This project was developed and deployed for remote monitoring of the data on the development of children with ASD in the remote setting in the Low-and-Middle-Income-Countries (LMICS). mCARE was deployed for two years among 300 children with ASD in Bangladesh’s four specialist autism care centers. Initially, mCARE’s had three aims to monitor the development of children (with ASD) development: (a) develop and deployment the mCARE app, (b) develop and deployment the mCARE data management platform, and (c) increase the ASD knowledge among the caregiver of the children with ASD. In this paper, we will evaluate and describe these three aims based on the two years of data from the mCARE project. After analyzing the data, we can conclude that this mCARE project could apply both the LMICs and developed countries for remote monitoring the children with ASD and increasing collective knowledge among the caregivers. • Measures efficacy of the Mobile-based Care application (mCARE) by collecting behavioral and milestone data from 300 children with ASD. • Data-driven proof for mCARE’s aims. • Determines the participants’ satisfaction level in this study. • Suggests mCARE as an effective tool for monitoring children with ASD.

Reduce, Reuse, and Recycle

Introduction: In program evaluation, time, and energy of program leaders and participants are often at a premium, and survey fatigue is a methodological challenge. Finding ways to reduce survey fatigue and burden on participants while also working to include multiple sources of evidence to answer evaluation questions is a key task of evaluators. Materials and Methods: Rasch modeling was used to build scales from Accreditation Council for Graduate Medical Education (ACGME) milestone data. Results: Existing data for related constructs were repurposed to address evaluation questions with minimal threat to construct validity. Discussion: This work illustrates a novel way to reuse and recycle existing data to build scales by using a psychometrically-sound survey development and measurement approach. Conclusion: This work illustrates an innovative methodology to combat participant survey fatigue and include multiple sources of evidence to answer evaluation questions.

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

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&gt;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.

Evaluation of multiple micronutrient supplementation and medium-quantity lipid-based nutrient supplementation in pregnancy on child development in rural Niger: A secondary analysis of a cluster randomized controlled trial.

BackgroundIt is estimated that over 250 million children under 5 years of age in low- and middle-income countries (LMICs) do not reach their full developmental potential. Poor maternal diet, anemia, and micronutrient deficiencies during pregnancy are associated with suboptimal neurodevelopmental outcomes in children. However, the effect of prenatal macronutrient and micronutrient supplementation on child development in LMIC settings remains unclear due to limited evidence from randomized trials.Methods and findingsWe conducted a 3-arm cluster-randomized trial (n = 53 clusters) that evaluated the efficacy of (1) prenatal multiple micronutrient supplementation (MMS; n = 18 clusters) and (2) lipid-based nutrient supplementation (LNS; n = 18 clusters) as compared to (3) routine iron–folic acid (IFA) supplementation (n = 17 clusters) among pregnant women in the rural district of Madarounfa, Niger, from March 2015 to August 2019 (ClinicalTrials.gov identifier NCT02145000). Children were followed until 2 years of age, and the Bayley Scales of Infant and Toddler Development III (BSID-III) were administered to children every 3 months from 6 to 24 months of age. Maternal report of WHO gross motor milestone achievement was assessed monthly from 3 to 24 months of age. An intention-to-treat analysis was followed. Child BSID-III data were available for 559, 492, and 581 singleton children in the MMS, LNS, and IFA groups, respectively. Child WHO motor milestone data were available for 691, 781, and 753 singleton children in the MMS, LNS, and IFA groups, respectively. Prenatal MMS had no effect on child BSID-III cognitive (standardized mean difference [SMD]: 0.21; 95% CI: −0.20, 0.62; p = 0.32), language (SMD: 0.16; 95% CI: −0.30, 0.61; p = 0.50) or motor scores (SMD: 0.18; 95% CI: −0.39, 0.74; p = 0.54) or on time to achievement of the WHO gross motor milestones as compared to IFA. Prenatal LNS had no effect on child BSID-III cognitive (SMD: 0.17; 95% CI: −0.15, 0.49; p = 0.29), language (SMD: 0.11; 95% CI: −0.22, 0.44; p = 0.53) or motor scores (SMD: −0.04; 95% CI: −0.46, 0.37; p = 0.85) at the 24-month endline visit as compared to IFA. However, the trajectory of BSID-III cognitive scores during the first 2 years of life differed between the groups with children in the LNS group having higher cognitive scores at 18 and 21 months (approximately 0.35 SD) as compared to the IFA group (p-value for difference in trajectory <0.001). Children whose mothers received LNS also had earlier achievement of sitting alone (hazard ratio [HR]: 1.57; 95% CI: 1.10 to 2.24; p = 0.01) and walking alone (1.52; 95% CI: 1.14 to 2.03; p = 0.004) as compared to IFA, but there was no effect on time to achievement of other motor milestones. A limitation of our study is that we assessed child development up to 2 years of age, and, therefore, we may have not captured effects that are easier to detect or emerge at older ages.ConclusionsThere was no benefit of prenatal MMS on child development outcomes up to 2 years of age as compared to IFA. There was evidence of an apparent positive effect of prenatal LNS on cognitive development trajectory and time to achievement of selected gross motor milestones.Trial registrationClinicalTrials.gov NCT02145000.

An Empirical Investigation Into Milestones Factor Structure Using National Data Derived From Clinical Competency Committees.

To investigate whether milestone data obtained from clinical competency committee (CCC) ratings in a single specialty reflected the 6 general competency domains framework. The authors examined milestone ratings from all 275 U.S. Accreditation Council for Graduate Medical Education-accredited categorical obstetrics and gynecology (OBGYN) programs from July 1, 2018, to June 30, 2019. The sample size ranged from 1,371 to 1,438 residents from 275 programs across 4 postgraduate years (PGYs), each with 2 assessment periods. The OBGYN milestones reporting form consisted of 28 subcompetencies under the 6 general competency domains. Milestone ratings were determined by each program's CCC. Intraclass correlations (ICCs) and design effects were calculated for each subcompetency by PGY and assessment period. A multilevel confirmatory factor analysis (CFA) perspective was used, and the pooled within-program covariance matrix was obtained to compare the fit of the 6-domain factor model against 3 other plausible models. Milestone ratings from 5,618 OBGYN residents were examined. Moderate to high ICCs and design effects greater than 2.0 were prevalent among all subcompetencies for both assessment periods, warranting the use of the multilevel approach in applying CFA to the milestone data. The theory-aided split-patient care (PC) factor model, which used the 6 general competency domains but also included 3 factors within the PC domain (obstetric technical skills, gynecology technical skills, and ambulatory care), was consistently shown as the best-fitting model across all PGYs by assessment period conditions, except for one. The findings indicate that in addition to using the 6 general competency domains framework in their rating process, CCCs may have further distinguished the PC competency domain into 3 meaningful factors. This study provides internal structure validity evidence for the milestones within a single specialty and may shed light on CCCs' understanding of the distinctive content embedded within the milestones.

Training and development in sport officials: A systematic review.

Sport officials make significant contributions to organized sport, yet scientific evidence to inform their specialized training and education at various levels has lagged. While psychological and performance demands of expert sport officials have been well documented, the extent of research about talent and expertise development, training efficacy, and broader developmental trajectories is unclear. This systematic review summarizes 30years of published findings on the study of training and development of sport officials, including areas of research interest, study designs, and sport official characteristics. A PRISMA systematic review was conducted, utilizing three scientific databases (Web of Science, SportsDiscus, PsycInfo) to identify relevant studies (N=27). Female participants were generally underrepresented in studies (17%), while football officials were most often represented (79%). Training intervention (59%), retrospective (37%), and cross-sectional comparison (22%) were the main study designs. Expert and near-expert sport officials' training histories and responses to empirically driven isolated-skills training represented the predominant areas of study. Sport-specific, video-based infraction detection tasks were the most frequently used training methods to improve perceptual-cognitive skills for on-field decision-making, however, studies lacked retention measures to on-field performance. Psychological skills training programs were found to have mixed effects and used varied criteria for measuring training efficacy. Physical training showed mainly significant effects on physiological measures and aging influences for on-field performance. More rigorous sport-specific evidence, assessments of training transfer, program efficacy, and macro-developmental trajectory and milestone data are needed to inform training programs and developmental plans.