Pediatric Pulmonary Milestones 2.0: Development, Lessons Learned, and Future Directions.

Pediatric pulmonology fellowship training programs are required by the Accreditation Council for Graduate Medical Education to report Pediatric Subspecialty Milestones biannually to track fellow progress. However, several issues, such as lack of subspecialty-specific context and ambiguous language, have raised concerns about their validity and applicability to use for fellow assessment and curriculum development. In this Perspective, we briefly share the process of the Pediatric Pulmonology Milestones 2.0 Work Group in creating new specialty-specific Milestones and tailoring information on the Harmonized Milestones to pediatric pulmonologists, with the goal of improving the Milestones' utility for stakeholders, including pulmonology fellows, faculty, program directors, and accrediting bodies. In addition, we created a supplemental guide to better link the Milestones to pulmonary-specific scenarios to create a shared mental model between stakeholders and remove a potential detriment to validity. Through the process, a number of guiding principles were clarified, including: 1) every Milestone should be able to be assessed independently, without overlap with other Milestones; 2) there should be clear developmental progression from one Milestone to the next; 3) Milestones should be based on the unique skills expected of pediatric pulmonologists; and 4) health equity should be a core component to highlight as a top priority to all stakeholders. In this Perspective, we describe these principles that guided formulation of the Pediatric Pulmonary Milestones to help familiarize the pediatric pulmonary community with the new Milestones. In addition, we share lessons learned and challenges in our process to inform other specialties that may soon participate in this process.

Clinician Educator Milestones: Assessing and Improving Educators' Skills.

ABSTRACT: The importance of the clinician educator (CE) role in the delivery of competency-based medical education is well-recognized. There is, however, no formal mechanism to identify when faculty have the knowledge, skills, and attitudes to be successful CEs. In 2020, the Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, Association of American Medical Colleges, and American Association of Colleges of Osteopathic Medicine convened a workgroup of 18 individuals representing multiple medical specialties and diverse institutions in the United States, including nonphysician educators, a medical student, and a resident, to develop a set of competencies, subcompetencies, and milestones for CEs.A 5-step process was used to create the Clinician Educator Milestones (CEMs). In step 1, the workgroup developed an initial CEM draft. Through brainstorming, 141 potential education-related CE tasks were identified. Descriptive statements for each competency and developmental trajectories for each subcompetency were developed and confirmed by consensus. The workgroup then created a supplemental guide, assessment tools, and additional resources. In step 2, a diverse group of CEs were surveyed in 2021 and provided feedback on the CEMs. In step 3, this feedback was used by the workgroup to refine the CEMs. In step 4, the second draft of the CEMs was submitted for public comment and the CEMs were finalized. In step 5, the final CEMs were released for public use in 2022.The CEMs consist of 1 foundational domain that focuses on commitment to lifelong learning, 4 additional domains of competence for the CE in the learning environment, and 20 subcompetencies. These milestones have many potential uses for CEs, including self-assessment, constructing learning and improvement plans, and designing systematic faculty development efforts. The CEMs will continue to evolve as they are applied in practice and as the role of CEs continues to grow and develop.

Systems-Based Practice 20 Years On: Navigating the System for Better Care.

ABSTRACT: Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

Pediatric Anesthesiology Milestones 2.0: An Update, Rationale, and Plan Forward.

Formal training in the subspecialty of pediatric anesthesiology began >60 years ago. Over the years, the duration and clinical work has varied, but what has stayed constant is a mission to develop clinically competent and professionally responsible pediatric anesthesiologists. Since accreditation in 1997, there has been additional guidance by the Accreditation Council on Graduate Medical Education (ACGME) and greater accountability to the public that we, indeed, are producing competent and professional pediatric anesthesiologists. This has been influenced by the slow evolution from time-based educational curriculum to a competency-based paradigm. As with all ACGME-accredited specialties, education leaders in pediatric anesthesiology first convened in 2014 to design specialty-specific developmental trajectories within the framework of the 6 core competencies, known as milestones, on which fellows were to be tracked during the 1-year fellowship. With 5 years of implementation, and substantial data and feedback, it has become clear that an iterative improvement was necessary to mirror the evolution of the profession. It was evident that the community required brevity and clarity in the next version of the milestones and required additional resources for assessment and faculty development. We describe here the methodology and considerations of our working group, guided by ACGME, in the rewriting of the milestones. We also provide suggestions for implementation and collaboration to support the education and assessment of pediatric anesthesiology fellows across the country.

Assessing Pediatric Rheumatology Fellow Competence in the Milestone Era: Past, Present, and Future.

Starting in 2015, pediatric rheumatology fellowship training programs were required by the Accreditation Council for Graduate Medical Education to assess fellows' academic performance within 21 subcompetencies falling under six competency domains. Each subcompetency had four or five milestone levels describing developmental progression of knowledge and skill acquisition. Milestones were standardized across all pediatric subspecialties. As part of the Milestones 2.0 revision project, the Accreditation Council for Graduate Medical Education convened a workgroup in 2022 to write pediatric rheumatology-specific milestones. Using adult rheumatology's Milestones 2.0 as a starting point, the workgroup revised the patient care and medical knowledge subcompetencies and milestones to reflect requirements and nuances of pediatric rheumatology care. Milestones within four remaining competency domains (professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) were standardized across all pediatric subspecialties, and therefore not revised. The workgroup created a supplemental guide with explanations of the intent of each subcompetency, 25 in total, and examples for each milestone level. The new milestones are an important step forward for competency-based medical education in pediatric rheumatology. However, challenges remain. Milestone level assignment is meant to be informed by results of multiple assessment methods. The lack of pediatric rheumatology-specific assessment tools typically result in clinical competency committees determining trainee milestone levels without such collated results as the foundation of their assessments. Although further advances in pediatric rheumatology fellowship competency-based medical education are needed, Milestones 2.0 importantly establishes the first pediatric-specific rheumatology Milestones to assess fellow performance during training and help measure readiness for independent practice.

Pediatric Infectious Diseases Milestones: A Step in the Right Direction to Evaluate Subspecialty Learners.

We share the work of the ACGME Pediatric Infectious Diseases Working Group in creating the Pediatric Infectious Diseases-Specific Milestones and discuss key considerations that lead to the reformation of competencies to better assess learners in Pediatric Infectious Diseases.

Accreditation Council for Graduate Medical Education Hand Surgery Milestones V2.0 Development and Implementation: What Fellowship Directors, Faculty, and Fellows Need to Know.

Milestones have been in effect for Accreditation Council for Graduate Medical Education-accredited hand surgery fellowships since 2015. In 2016, the Accreditation Council for Graduate Medical Education began an improvement process to make the milestones easier to read, understand, and assess. This article looks at the process used for hand surgery, makes comparisons between the two versions, and discusses the resulting changes. A representative group of hand surgery faculty and fellows worked together to review the milestones data and identify necessary changes. Working iteratively in large and small groups, the milestones were edited, and a supplemental guide was developed. The new hand surgery milestones have fewer patient care subcompetencies, yet include the same overarching themes. The medical knowledge subcompetencies have been reduced to four, and they now focus on key dimensions of knowledge development instead of pure anatomical knowledge. Systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills include subcompetencies harmonized with all other accredited programs. Finally, the supplemental guide was created as an aid to clinical competency committees to provide clear understanding of the intent of the milestones. The guide includes examples for individual milestones, ideas for how to assess each subcompetency, and resources for faculty and fellows alike. The new hand surgery milestones were designed to be clearer and easier for clinical competency committees to evaluate and for faculty and fellows to understand. The accompanying supplemental guide is a new addition that will help individual programs better understand how to implement these changes. The new hand surgery milestones can be found at https://www.acgme.org/globalassets/pdfs/milestones/handsurgerymilestones.pdf.

What to know about 2.0: Revisions to the pediatric emergency medicine milestones.

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) adopted educational milestones for trainee assessment in 2013, as a key component of the Next Accreditation System. Two years later, the ACGME, American Board of Pediatrics (ABP), and American Board of Emergency Medicine (ABEM) collaborated to create specialty-specific subcompetencies in pediatric emergency medicine (PEM). Since that time, emerging data have demonstrated the need to revise specialty milestones. Consequently, the ACGME summoned a working group to revise the original PEM milestones. Methods: The PEM Milestones 2.0 Working Group convened in April 2021, comprising diverse representation from ACGME staff, PEM and EM attendings, PEM fellowship program directors, PEM fellows, and community members, overseen by the ACGME's vice president for milestones development. The group met virtually six times over 3 months, with concurrent independent and subgroup work, to draft the PEM Milestones 2.0 and supplemental guide. Results: The working group's revisions generated concise descriptions of behavioral anchors to define skill acquisition more accurately; attention to the transition from residency to fellowship training; incorporation of harmonized milestones for non-patient care and non-medical knowledge domains; and increased emphasis on diversity, equity, and inclusion. A supplemental guide was also designed to aid programs in designing programmatic assessment related to specialty-specific milestones. Conclusions: The PEM Milestones 2.0 provide an updated, specialty-specific framework to guide the development and assessment of PEM fellows and training programs. Future work may focus on faculty and learner development, advancing validity evidence, strengthening content expertise, and integrating milestones with specialty-specific entrustable professional activities.

A new era of assessment for neonatal-perinatal medicine trainees: milestones 2.0.

To optimize post-graduate competency-based assessment for medical trainees, the Accreditation Council for Graduate Medical Education initiated a sub-specialty-specific revision of the existing Milestones 1.0 assessment framework in 2016. This effort was intended to increase both the effectiveness and accessibility of the assessment tools by incorporating specialty-specific performance expectations for medical knowledge and patient care competencies; decreasing item length and complexity; minimizing inconsistencies across specialties through the development of common "harmonized" milestones; and providing supplemental materials, including examples of expected behaviors at each developmental level, suggested assessment strategies, and relevant resources. This manuscript describes the efforts of the Neonatal-Perinatal Medicine Milestones 2.0 Working Group, outlines the overall intent of Milestones 2.0, compares the novel Milestones to the original version, and details the materials contained in the novel supplemental guide. This new tool should enhance NPM fellow assessment and professional development while maintaining consistent performance expectations across specialties.

Looking back, moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0.

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.

Evolution of Accredited Pediatric Cardiac Anesthesiology Fellowship Training in the United States: A Step in the Right Direction.

Pediatric cardiac anesthesiology has developed as a subsubspecialty of anesthesiology over the past 70 years. The evolution of this specialty has led to the establishment in 2005 of a dedicated professional society, the Congenital Cardiac Anesthesia Society (CCAS). By 2010, multiple training pathways for pediatric cardiac anesthesia emerged. Eight programs in the United States offered advanced pediatric cardiac anesthesia with variable duration, ranging from 3 to 12 months. Other programs offered a combined fellow/staff position for 1 year. The need for a standardized training pathway was recognized by the Pediatric Anesthesia Leadership Council (PALC) and CCAS in 2014. Specifically, it was recommended that pediatric cardiac anesthesiology be a second, 12-month advanced fellowship following pediatric anesthesia to acquire skills unique from those acquired during a pediatric anesthesia fellowship. This was reiterated in 2018, when specific pediatric cardiac anesthesia training milestones were developed through consensus by the CCAS leadership. However, given the continuous increasing demand for well-trained pediatric cardiac anesthesiologists, it is essential that a supply of comprehensively trained physicians exists. High-quality training programs are therefore necessary to ensure excellent clinical care and enhanced patient safety. Currently, there are 23 programs offering one or more positions for 1-year pediatric cardiac anesthesia fellowship. Due to the diverse curriculum and evaluation process, formalization of the training with accreditation through the Accreditation Council for Graduate Medical Education (ACGME) was the obvious next step. Initial inquiry started in April 2020. The ACGME recognized pediatric cardiac anesthesia as a subsubspecialty in February 2021. The program requirements and milestones for the 1-year fellowship training were developed in 2021 and 2022. This special article reviews the history of pediatric cardiac anesthesia training, the ACGME application process, the development of program requirements and milestones, and implementation.

Emergency medical services Milestones 2.0: What has changed?

Background: Since 2015, development of competencies by emergency medical services (EMS) fellows have been evaluated using the EMS Milestones 1.0 developed by a working group consisting of relevant stakeholders convened by the Accreditation Council for Graduate Medical Education (ACGME). Feedback from users and data collected from the milestones assessments in the interim indicated a need for revision of the original milestones. In May 2021, the Milestones 2.0 working group was convened for the purpose of revising this specialty-specific assessment tool. Methods: A working group consisting of representatives from American Board of Emergency Medicine, the Review Committee for Emergency Medicine, and volunteers selected by the ACGME Milestones Committee, chaired by the ACGME vice president for milestones development, was convened using a virtual platform to revise the milestones and develop a supplemental guide for use along with the Milestones 2.0. There were no in-person meetings of this working group due to the COVID-19 pandemic. Results: Data from milestones reporting, discussion within the working group, stakeholder input, and public commentary were used to revise the original milestones. A new supplemental guide to enhance milestone usability and provide recommended resource materials was also developed for use alongside the milestones. Discussion: The EMS Milestones 2.0 and accompanying supplemental guide provide an updated framework for fellowship programs to use as a guide for developing the competencies necessary for independent practice as EMS physicians and in the formal, competency-based evaluation of trainees as required by the ACGME.

Milestones 2.0: An advancement in competency-based assessment for dermatology.

In 2013, Next Accreditation System and Milestones became the competency-based assessment framework required for all specialties accredited by the Accreditation Council for Graduate Medical Education. Dermatology residency programs implemented Milestones 1.0 in the 2013-2014 academic year. The Accreditation Council for Graduate Medical Education committed to review and revise Milestones 1.0 within 3 to 5 years. Subsequently, feedback from key stakeholders influenced the goals for revision, including reducing complexity, enhancing community engagement, and providing additional resources for programs. In 2019, the Dermatology Milestones 2.0 work group streamlined the specialty-specific patient care and medical knowledge subcompetencies. The harmonized milestones allowed for greater uniformity across specialties in systems-based practice, practice-based learning and improvement, professionalism, and interpersonal communication and skills. The work group developed a supplemental guide with specialty-specific context to help program directors, clinical competency committee members, and other faculty understand individual milestones. Dermatology Milestones 2.0 reduces the number of subcompetencies from 28 to 21. Milestones 2.0 represents an advancement in competency-based assessment for dermatology. The first year of reporting for Dermatology Milestones 2.0 is 2021.

Pediatric surgery milestones 2.0: A primer.

More than twenty years ago, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties began the conversion of graduate medical education from a structure- and process-based model to a competency-based framework. The educational outcomes assessment tool, known as the Milestones, was introduced in 2013 for seven specialties and by 2015 for the remaining specialties, including pediatric surgery. Designed to be an iterative process with improvements over time based on feedback and evidence-based literature, the Milestones started the evolution from 1.0 to 2.0 in 2016. The formation of Pediatric Surgery Milestones 2.0 began in 2019 and was finalized in 2021 for implementation in the 2022-2023 academic year. Milestones 2.0 are fewer in number and are stated in more straightforward language. It incorporated the harmonized milestones, subcompetencies for non-patient care and non-medical knowledge that are consistent across all medical and surgical specialties. There is a new Supplemental Guide that lists examples, references and links to other assessment tools and resources for each subcompetency. Milestones 2.0 represents a continuous process of feedback, literature review and revision with goals of improving patient care and maintaining public trust in graduate medical education's ability to self-regulate. LEVEL OF EVIDENCE: V.

Qualitative Study of Orthopedic Surgery Milestones 1.0: Burdens and Benefits.

OBJECTIVE: The purpose of this study was to explore the context and mechanisms by which the first set of Milestones impacted the processes of the Clinical Competency Committee, how programs have incorporated the Milestones into their program, and to understand more about the resident perspective in order to improve Orthopedic Surgery Milestones. DESIGN, SETTING, AND PARTICIPANTS: In 2020 all 201 accredited orthopedic surgery residency programs were invited to participate in qualitative telephone interviews to assess their experience with the Milestones and complete a supplemental online survey about their Clinical Competency Committee. Participants were comprised of a self-selected sample and complemented by a purposeful sample to ensure a breadth of perspectives. Interview data were analyzed using template analysis. Survey data were analyzed with descriptive statistics. RESULTS: Interviews were completed with 101 individuals from 47 programs (23% of all programs). The two overarching themes were implementation and impact of Milestones. Subthemes within implementation were substantial variability in approaches to Milestone use in curriculum and assessment, faculty development, and methods to introduce residents to the Milestones assessment framework. The large number of subcompetencies created a significant burden for almost all programs. The structure of the Milestones was also viewed as poorly aligned with the variable design of rotation schedules across programs. Milestones have the potential to offer valuable feedback for trainees and programs overall. CONCLUSIONS/APPLICATION: While some benefits were noted and most programs appreciated the intent, the structure and design of the initial set of orthopedic surgery Milestones created substantial challenges for these programs. The results of this study helped guide a revision of the Orthopedic Surgery Milestones. These results can also be used by program leadership to encourage reflection around past, current, and future utilization of the Milestones framework. Further research will be needed to determine the impact of the revision on programs.

A multispecialty ethnographic study of clinical competency committees (CCCs).

PURPOSE: Clinical competency committees (CCCs) assess residents' performance on their specialty specific milestones, however there is no 'one-size fits all' blueprint for accomplishing this. Thus, CCCs have had to develop their own procedures. The goal of this study was to examine these efforts to assist new programs embarking on this venture and established programs looking to improve their CCC practices and processes. METHODS: We purposefully sampled CCCs across multiple specialties and institutions. Data from three sources were triangulated: (1) online demographic survey, (2) ethnographic observations of CCC meetings and (3) post-observation semi-structured interviews with the program director and/or CCC chairperson. Template analysis was used to build the coding structure. RESULTS: Sixteen observations were completed with 15 different CCCs at 9 institutions. Three main thematic categories that impact the operations of CCCs emerged: (1) Membership structure and members roles, (2) Roles of the CCC in residency and 3) CCC processes, including trainee presentation to the committee and decision-making. While effective practices were observed, substantial variation existed in all three thematic areas. CONCLUSIONS: While CCCs used some known effective practices, substantial variation in structure and processes was notable across CCCs. Future work should explore the impact of this variation on educational outcomes.