Teaching the Teachers With Milestones: Using the ACGME Milestones Model for Professional Development

Abstract

Physicians-in-training are educated through the paradigm of competency-based medical education (CBME), which promotes progressive development of expertise. To better support CBME, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Milestones assessment framework across all ACGME-accredited graduate medical education (GME) training programs.1,2 Milestones are behavioral descriptions of the developmental trajectory of trainees in the GME environment, which provide longitudinal and trajectory-based metrics along domains of physician competency. These metrics aim to promote lifelong learning and ensure residents and fellows are “ready for autonomous practice” at graduation. Yet, such “readiness for autonomous practice” at the completion of training does not equate with the completion of professional learning, nor does it preclude the development of further levels of expertise.To ensure ongoing professional development following training, continuing medical education (CME) and continuing certification initiatives have aimed to maintain and expand competence via meaningful feedback in an iterative, safe, and interactive process for practicing clinicians.3–5 However, as currently implemented, CME has been criticized with cost concerns, burden, complexity, lack of authenticity to practice, and insufficient linkage to GME. In this context, novel ideas to promote professional development are needed for practicing physicians. For certain skills, a trajectory-based framework (akin to the concept of the Milestones) in CME could more closely align expectations of new graduates within the context of realistic practice settings, providing a framework for further ongoing professional development.Extending the Milestones framework to faculty development may promote structured professional development as a core of advancement and provide a unified approach to faculty development. However, there are multiple barriers to the incorporation of this framework across all CME initiatives, including the risk of added administrative burdens, identification of experts to create such Milestones, and logistical challenges of ensuring validity of assessment strategies. We therefore propose using this framework for discrete skills and focused career paths, such as for practicing clinician-educators, which may be the ideal setting for this approach. By using a Milestones system in clinician-educator faculty, longitudinal and trajectory-based metrics along specific educator domains could be delineated for self-improvement and individual skill development, with clear metrics for advancement and promotion for institutions.A Milestones framework for the professional development of clinician-educators could be advantageous for many reasons. First, the universality of educator skills (even across myriad domains) are prime for ubiquitous trajectory-based faculty development. As educators in the era of CBME, we are familiar with using Milestones for GME learner assessment. Using existing medical education frameworks, such as the Dreyfus model, faculty Milestones could focus on the fundamental skills necessary to excel as a clinician-educator. These could also provide unique opportunities for self-assessment and self-directed learning across discrete areas, such as in administration, research, and curricular development, beyond what is currently available through traditional CME programs. Operationalizing the Milestones in the ongoing development of clinician-educators could be the next big step forward in professional development for physicians, highlighting a novel pathway for CME.While novel in the CME sphere, this paradigm of progressive attainment of expertise has already been successfully implemented in other education settings. In K–12 settings, educators may engage in a robust series of assessments to seek certification as National Board-Certified Teachers (NBCTs). Requirements include completion of a “rigorous, content-specific, performance-based, and reflective portfolio…well beyond requirements for initial teacher licensure” in multiple content areas (Table).6 Achievement of NBCT status in K–12 educators has been associated with improved student performance7 and diminished teacher attrition. The medical education community could create similar standards and enhance the interoperability of instructional design, assessment, and the clinical learning environment for clinician-educators, although it is important to note that this program is voluntary for educators (with likely significant intrinsic motivation). However, this could make our learners' experiences more consistent nationwide and across the medical education continuum. It could inform a research agenda to identify better practices, reduce inefficiencies and redundancies, and add value to medical education.8Beyond providing discrete areas of self-improvement, the Milestones system could additionally serve as an important component of promotional criteri