ACGME launched milestone assessments in 2013, formally introducing a developmental framework to gauge the learning trajectory of residents along six core competencies (medical knowledge, patient care, systems-based practice, practice-based learning and improvement, communication, and professionalism). Each competency contains subcompetencies to further specify key skill areas. ACGME required all ACGME-accredited programs to form clinical competency committees (CCCs) to review residents’ written evaluations and assess their achievement of the subcompetencies semi-annually. Residents should demonstrate progression along competency-based descriptors, called milestones, throughout training. Levels do not correspond with post-graduate year—trainees may progress in achievement at varying paces. Milestone assessments are meant to be formative but are reported outside of the program.
(See the figure for the life cycle of milestones assessments, including major inputs and outputs.)
After extensive validity research and input from key stakeholders, ACGME released Milestones 2.0 for Internal Medicine in July 2021 with the goal of improved clarity and harmonization across training fields.1 New competencies emphasize residents’ ability to meet societal needs related to social determinants of health and knowledge of health systems and patients’ payment models when creating care plans. The new assessment scale emphasizes growth mindsets—interns may receive a level of 1 without being “critically deficient.” Supplemental Guides on the ACGME website describe the rationale behind changes and offer assessment tools and resources.2
Milestones 2.0 presents an opportunity for programs to re-evaluate current assessment methods and improve them—but doing so requires significant up-front time and training. In the revision of evaluation tools, program leaders must consider where performance relevant to each new subcompetency is observed. This requires balancing detail with ease of completion so CCCs can gather adequate assessment data without overburdening faculty observers. Programs may need to create faculty tools for direct observation of skills (e.g., history-taking, counseling, procedures). Programs may need to design peer evaluation tools to inform milestone achievements in team leadership and communication. Programs may take advantage of evaluation tool-sharing available through evaluation software systems; however, these will require revision to ensure local relevance.
Faculty development and protected time remain key to successful transition into Milestones 2.0 assessments. Faculty training should focus on appropriate use of evaluation tools, direct observation for competency-based assessments, re-calibration of current assessment scales, and delivery of actionable feedback to trainees. Any new technology for evaluation tools will require further faculty training in its use. Institutions must also allow faculty time for on-the-job direct observation, which may require longer patient visits or additional faculty preceptors. Academic leaders should also expect increased time needed for faculty members on CCCs to learn new milestones and incorporate data from a mix of old and new evaluation tools for accurate assessments of residents during the transition. Overall, Milestones 2.0 offers an important next step in competency-based assessment of residents.