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ACGME Milestones: A Great Idea Falling Short of its Potential

Placing constraints on the use of the ACGME milestones: A commentary on the limitations of global performance ratings. Williams RG et al. Academic Medicine 2015;90:404-407.


Reviewed by Chris White

What was the study question?
Four nationally recognized clinical educators express concerns about how the ACGME educational milestones are being implemented in residency training programs.

How was the study done?
The authors discuss the role of humans in evaluating learner performance and provide four examples of increasingly complex situations in which resident performance is evaluated. In the first three examples, direct observation is required. Only in the last situation (global end-of-performance rating) is the evaluation based upon the opinion of the evaluator. For the majority of milestones markers to be effective, faculty need to directly observe resident performance and provide their feedback and ratings soon after.

What were the results?
The authors believe that in the majority of residency training programs, the milestones are not being implemented as intended. Instead, they simply become more items added to the global end-of-rotation rating form. When used in this manner, they only increase the workload of faculty without providing new or useful information about the competency of residents, since they are not based upon direct observations.

What are the implications of these findings?
The authors' concerns have become reality at my institution, and I suspect many others as well. More direct observation of resident performance is needed, yet faculty have less time for observing residents and medical students in the increasing clinical revenue-dependent model of academic medical education. Unless something changes this situation, "the milestones movement will fall short of its intention and potential."

Editor's note: This article highlights a critical aspect of competency-based education: trainees must be observed and this is hard to do. I wonder what COMSEP can do to support our clerkship directors and their faculty in this regard (SLB).

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