Emergency Medicine Milestones Final Ratings Are Often Subpar.

Background: The emergency medicine (EM) milestones are objective behaviors that are categorized into thematic domains called "subcompetencies" (eg, emergency stabilization). The scale for rating milestones is predicated on the assumption that a rating (level) of 1.0 corresponds to an incoming EM-1 resident and a rating of 4.0 is the "target rating" (albeit not an expectation) for a graduating resident. Our aim in this study was to determine the frequency with which graduating residents received the target milestone ratings. Methods: This retrospective, cross-sectional study was a secondary analysis of a dataset used in a prior study but was not reported previously. We analyzed milestone subcompetency ratings from April 25-June 24, 2022 for categorical EM residents in their final year of training. Ratings were dichotomized as meeting the expected level at the time of program completion (ratings of ≥3.5) and not meeting the expected level at the time of program completion (ratings of ≤3.0). We calculated the number of residents who did not achieve target ratings for each of the subcompetencies. Results: In Spring 2022, of the 2,637 residents in the spring of their last year of training, 1,613 (61.2%) achieved a rating of ≥3.5 on every subcompetency and 1,024 (38.8%) failed to achieve that rating on at least one subcompetency. There were 250 residents (9.5%) who failed to achieve half of their expected subcompetency ratings and 105 (4.0%) who failed to achieve the expected rating (ie, rating was ≤3.0) on every subcompetency. Conclusion: When using an EM milestone rating threshold of 3.5, only 61.2% of physicians achieved the target ratings for program graduation; 4.0% of physicians failed to achieve target ratings for any milestone subcompetency; and 9.5% of physicians failed to achieve the target ratings for graduating residents in half of the subcompetencies.

Comparison of performance data between emergency medicine 1-3 and 1-4 program formats.

Objective: This study compares performance data from physicians completing 3-year versus 4-year emergency medicine residency training programs. Currently, there are 2 training formats and little is known about objective performance differences. Methods: This was a retrospective cross-sectional analysis of emergency residents and physicians. Multiple analyses were conducted comparing physicians' performances, including Accreditation Council of Graduate Medical Education Milestones and American Board of Emergency Medicine In-training Examination (ITE), Qualifying Examination (QE), Oral Certification Examination (OCE), and program extensions from 3-year and 4-year residency programs. Some confounding variables were not or could not be considered, such as rationale for medical students to choose one format over another, as well as application and final match rates. Results: Milestone scores are higher for emergency medicine 3 residents in 1-3 programs (3.51) versus emergency medicine 3 residents in 1-4 programs (3.07; P < 0.001, d = 1.47) and highest for emergency medicine 4 residents (3.67). There was no significant difference in program extension rates (emergency medicine 1-3, 8.1%; emergency medicine 1-4, 9.6%; P = 0.05, ω = 0.02). ITE scores were higher for emergency medicine 1, 2, and 3 residents from 1-3 programs and emergency medicine 4 residents from 1-4 programs scored highest. Mean QE score was slightly higher for emergency 1-3 physicians (83.55 vs 83.00; P < 0.01, d = 0.10). QE pass rate was higher for emergency 1-3 physicians (93.1% vs 90.8%; P < 0.001, ω = 0.08). Mean OCE score was slightly higher for emergency 1-4 physicians (5.67 vs 5.65; P = 0.03, d = -0.07) but did not reach a priori statistical significance (α < 0.01). OCE pass rate was also slightly higher for emergency 1-4 physicians (96.9% vs 95.5%; P = 0.06, ω = -0.07) but also non-significant. Conclusions: These results suggest that although performance measures demonstrate small differences between physicians from emergency medicine 1-3 and 1-4 programs, these differences are limited in their ability to make causal claims about performance on the basis of program format alone.

The emergency medicine milestones: a validation study.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties sought to define milestones for skill and knowledge acquisition during residency training. Milestones are significant objective observable events. The milestones are listed within a structure that is derived from the ACGME general competencies. Major groups of milestones are called "subcompetencies." The original 24 subcompetencies containing 255 milestones for emergency medicine (EM) were developed through a multiorganizational group representing most EM stakeholder groups. To assure that the milestones reflected EM resident progress throughout training, the EM Milestones Working Group (EM MWG) sought to validate the individual milestones. METHODS: A computer-based survey was sent to all EM residency programs. The survey period began on April 30, 2012, and concluded on May 15, 2012. Respondents were asked to assign each milestone to a specific level of skill or knowledge acquisition. These levels ranged from a beginning resident to an accomplished clinician. There were two different forms that divided the milestones into two groups of 12 subcompetencies each. Surveys were randomly assigned to programs. RESULTS: There were five respondents (the program director and four key faculty) requested from each of the 159 residences. There were responses from 96 programs (60.4%). Of the 795 survey recipients, 28 were excluded due to prior exposure to the EM milestones. Of the remaining 767 potential respondents, 281 completed the survey (36.6%) within a 16-day period. Based on the survey results, the working group adjusted the milestones in the following ways: one entire subcompetency (teaching) was eliminated, six new milestones were created, 34 milestones were eliminated, 26 milestones were reassigned to a lower level score, and 20 were reassigned to a higher level. Nineteen milestones were edited to provide greater clarity. The final result was 227 discrete milestones among 23 subcompetencies. CONCLUSIONS: The EM milestones were validated through a milestone assignment process using a computer-based survey completed by program directors and key faculty. Milestones were revised in accordance with the results to better align assignment within each performance level.

The development of the emergency medicine milestones.

The Accreditation Council for Graduate Medical Education (ACGME) has outlined its "Next Accreditation System" (NAS) that will focus on resident and residency outcome measurements. Emergency medicine (EM) is one of seven specialties that will implement the NAS beginning July 2013. All other specialties will follow in July 2014. A key component of the NAS is the development of assessable milestones, which are explicit accomplishments or behaviors that occur during the process of residency education. Milestones describe competencies more specifically and identify specialty-specific knowledge, skills, attitudes, and behaviors (KSABs) that can be used as outcome measures within the general competencies. The ACGME and the American Board of Emergency Medicine (ABEM) convened an EM milestone working group to develop the EM milestones. This article describes the development, use within the NAS, and challenges of the EM milestones.

A novel comprehensive in-training examination course can improve residency-wide scores.

INTRODUCTION: The annual American Board of Emergency Medicine (ABEM) in-training examination is a tool to assess resident progress and knowledge. We implemented a course at the New York-Presbyterian Emergency Medicine Residency Program to improve ABEM scores and evaluate its effect. Previously, the examination was not emphasized and resident performance was lower than expected. METHODS: As an adjunct to required weekly residency conferences, an intensive 14-week in-training examination preparation program was developed that included lectures, pre-tests, high-yield study sheets, and a remediation program. We compared each residents in-training examination score to the postgraduate year-matched national mean. Scores before and after course implementation were evaluated by repeat measures regression modeling. Residency performance was evaluated by comparing residency average to the national average each year and by tracking ABEM national written examination pass rates. RESULTS: Following the course's introduction, odds of a resident scoring higher than the national average increased by 3.9 (95% CI 1.9-7.3) and percentage of residents exceeding the national average increased by 37% (95% CI 23%-52%). In the time since the course was started the overall residency mean score has outperformed the national average and the first-time ABEM written examination board pass rate has been 100%. CONCLUSION: A multifaceted residency-wide examination curriculum focused around an intensive 14-week course was associated with marked improvement on the in-training examination.