Session Summary: SES118 – Milestones Five Years On: Lessons Learned and Practical Approaches to Improve Value

“Milestones” has been a part of the ACGME vocabulary for nearly 17 years now. In the final session of the 2018 Annual Educational Conference, Eric Holmboe, MD, MACP, FRCP, senior vice president, Milestone Development and Evaluation, kicked off a discussion about the Milestones today and the Milestones to come.

Dr. Holmboe identified the goal of competency-based Milestones as achieving the Institute for Healthcare Improvement’s quadruple aim: better outcomes, lower costs, improved patient experience, and improved clinician experience.

He summarized the history of the Milestones, dating back to the 2001 Outcomes Project, through which curriculum and assessment began to inform each other. He spoke of medical education as a developmental process with the ultimate goal of reaching expertise and the ultimate audience as the public.

Finally, he touched upon the model for developmental stages of the Milestones – novice, advanced beginner, competent, proficient, and expert, and emphasized that learning does not happen in a straight line.

“People go through stages of development, working toward proficiency,” he said. “But no one comes out exactly the same. So how do we keep them on the journey toward expertise?”

One way, he said, is by ensuring a shared mental model between the learner and the coach.

Analyzing the Data
Stanley Hamstra, PhD, ACGME vice president, Milestone Research and Evaluation, discussed using the Milestones for learning analytics.

“There are 2.8 million data points every six months for the Milestones,” he shared, “which presents both unique challenges and opportunities.”

Dr. Hamstra emphasized that data is the starting point in analyzing specialties and their results, but that we need to get at what the data represent. Conversations with program directors and others are just as crucial to the learning process. With this combined information, a national-level dialogue is taking place.

Dr. Hamstra thanked the community for its efforts in this area, highlighting the importance of clear communication and collaboration within the Milestones process, as well as the ACGME’s duty to report to the public.

The 2017 Milestones Report, with more data and enhancements, is targeted for publication in September 2018, Dr. Hamstra said.

Milestones 2.0
After exploring the past and present Milestones, Laura Edgar, EdD, CAE, ACGME executive director, Milestones Development and for the Review Committee for Medical Genetics and Genomics, dove into the future with a discussion of what’s now been dubbed “Milestones 2.0.”

“How are you using Milestones to help you with your residents?,” Dr. Edgar asked conference attendees, and then pivoted to ask, “Are you ready for Milestones 2.0?”

From the start, the ACGME has always been forthright about its commitment to reviewing and updating the Milestones if needed at the five year mark. Now is that time, and we have the opportunity to make improvements with all of the feedback gathered from the community through hundreds of meetings and five years of data. Examples of areas being considered in this revision process:

• Too many subcompetencies
• Complex language
• Challenges in accurately evaluating
• Interest in participation by others, including junior faculty members

The Milestones team initiated 2.0 thinking with the intent to create a set of what they are now calling “Harmonized Milestones.” Neurological surgery piloted these in 2017, and 12 other specialties are in the process of developing theirs. More core specialties will start the 2.0 revision process in 2018 or 2019, with all subspecialties to follow and implement their Milestones 2.0 by 2020.

As these new Milestones documents roll out, some of the differences the community will see include:

• A call for volunteers to join the Working Groups – anyone involved in medical education can qualify
• Participation by public members
• Data decisions led by specialty, rather than expert consensus
• A survey of program directors in the beginning of the process

Dr. Edgar reviewed the Milestones section of the ACGME website with the crowd, and pointed them to Guides and other resources and materials to help them along the way. She announced that Supplemental Guides are being created in tandem with the specialty Milestones revisions that include examples, assessment tools, and resources, as well as implementation tips for continuous quality improvement.

To round out the session, Dr. Edgar encouraged the audience to e-mail milestones@acgme.org with any questions or ideas for collaboration, and to participate in Milestones assessment courses and distance learning modules to optimize the Milestones experience.

Stay tuned for more information about the Milestones as the 2.0 revision process unfolds over the next few years!