We propose this list of milestones to promote competency-based training in internal medicine. Residency program directors may use them to track the progress of trainees in the 6 general competencies and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking,17
assist remediation by facilitating identification of specific deficits, and provide a degree of national standardization in evaluation. Finally, by explicitly enumerating the profession's expectations for graduates, they may improve public accountability for residency training.
It is worth noting that many of the milestones—particularly in practice-based learning and improvement, systems-based practice, communication and interpersonal skills, and professionalism competencies—are not unique to internal medicine. Physicians in any specialty should demonstrate competence in these “horizontal” dimensions of clinical practice. Thus, educators in other specialties may adopt some of our work as they develop milestones for their residency programs.
Some may find that the “generous” time frames set a low bar, believing that residents should reach some of the early milestones sooner. Indeed, in keeping with our decision to set a floor rather than a ceiling, we set the time frames with the expectation that a resident's failure to reach them would trigger further assessment and possibly remediation. At a programmatic level, a significant deviation from the expected progression along the milestones may trigger an accreditation action. Thus, we expect that many normally progressing residents will reach many of the milestones in advance of the “deadline.” A few exceptional graduating medical students may even begin their internship part of the way “down the road.” Finally, these time frames represent a starting point of an ongoing dialogue. We expect them to be refined based on the implementation pilot projects planned for the next phase.
We also anticipate that some program directors, weary from complying with the “musts” and “shoulds” handed down from the ACGME, may receive the milestones as yet another bureaucratic burden. On the contrary, we foresee the milestones making their jobs easier. The specific observable behaviors embodied in them, for instance, should assist
program directors, who have hitherto struggled to translate the more general language of the 6 competencies into concrete assessments.18
Nor should this initiative stifle creativity and innovation. In the spirit of the Outcome Project, program directors remain free to develop innovative structures, curricula, and evaluation systems, provided they demonstrate learning “outcomes” in the 6 competencies, which are now elaborated in the milestones. Finally, we expect that residents, who often receive feedback lacking a specific action plan,19
will welcome the more actionable feedback afforded by the milestones framework.
Of course, “This is not the end,” as Churchill said in 1942. “It is not even the beginning of the end. But it is, perhaps, the end of the beginning.” More work is needed before these milestones can be successfully integrated into competency-based evaluation systems. Specifically, we will solicit commentary from the broader medical education community to help us refine the proposed milestones and correct any omissions or redundancies. We must also articulate concrete behavioral anchors for each developmental stage, identify psychometrically robust and feasible evaluation instruments to assess residents' progress, and train faculty to use these instruments effectively.20
Finally, we will learn practical lessons from the initial implementation experience, as diverse residency programs, beginning with pilot projects, integrate developmental milestones into their evaluation systems.
This will be a challenging task but, we believe, one that is well within our reach. We do not share the skepticism of others who lament the perceived inadequacy of currently available evaluation instruments.21
On the contrary, the “tool box” contains many robust instruments.22–,29
The problem lies in the variable use of the instruments by faculty who do not share a common understanding of expected behaviors.30
The milestones provide a set of consistent expectations that should reduce this variability.
As representatives of the internal medicine education community, we articulated the milestones to embody our vision of the development of a competent internist. We ask the ACGME only to hold us to this standard.