Author + information
- Chandrasekar Palaniswamy, MD∗ ()
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Chandrasekar Palaniswamy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, P.O. Box 1030, New York, New York 10029.
In 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified 6 core competency domains required during residency training for all specialties. These competencies include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The traditional model of residency and fellowship training was defined by a curriculum that was based on time in training rather than on attainment of competency. This model largely focused on defining the “finish line” of training by demonstrating acquisition of specific knowledge through certification examinations. Acquisition of skills and attitudes were not considered in this model in defining the completion of training. The newer model of competency-based training focuses on achievement of specific goals and objectives of the curriculum.
In 2007, the American Board of Internal Medicine and the ACGME convened a task force that culminated in identification of “milestones” for competency-based training (1). Milestones are a set of specific, observable skills, attitudes, and knowledge that represent important intermediate points across the 6 ACGME core competencies. These milestones provide a criterion-based framework for performance to help training programs assess the progression of a trainee. This aims to produce highly competent physicians to meet the expectations and health care needs of the public. The programs are now required to demonstrate that their trainees have acquired these behaviors to advance in training. The Internal Medicine Subspecialty Milestones Project lists 23 milestones that are designed for programs to use in a semiannual fashion to assess fellows’ performance (2). They are summarized in Table 1. The milestones are arranged in columns of progressive stages of competence: not yet assessable, critical deficiencies, ready for unsupervised practice, and aspirational (exceptional). The column “ready for unsupervised practice” is designed as the graduation target, but it does not represent a graduation requirement at this point. The Next Accreditation System mandates that medical subspecialty training programs now document achievement of competency through milestones, representing a paradigm shift in the process of graduate medical education in the United States (3).
In a specialty such as cardiology, where procedures require a combination of motor skills, judgment, and medical knowledge, accurate assessment of competency can be particularly challenging. Although procedural skills are not explicitly included as 1 of the core competencies, it can be surmised that this will include aspects of all 6 competencies. It is imperative to develop an objective tool for assessment of competency in common procedures. The best tools are those that consistently measure the performance objectives with minimal sampling error, even with different evaluators. For instance, a sample objective assessment of technical skill for cardiac catheterization can include the following: appropriateness of indication for the procedure, weighing the risks versus benefit of the procedure, knowledge of relevant anatomy, familiarity with equipment, performance of the procedure, interpretation of angiographic data, management decisions based on results, and monitoring for complications. Feedback about procedural performance should be provided to the fellow as soon as possible after the procedure is completed. With progressive experience and competence, the fellow can be assigned more complex procedures.
Although the adoption of competency-based training will enhance opportunities for early identification of struggling fellows, this system is not without flaws. Significant anomalies in the learning curve do exist, where some fellows may be slow learners but ultimately end up matching or outperforming their peers before the end of their training. Qualities such as humanism, selflessness, and professionalism are difficult to measure in objective terms.
In an ideal training environment, the fellows should feel free to confront their weaknesses without fear of failure. When performance becomes the primary criterion to determine the progression through training, a fellow may purposefully hide his or her weakness from the evaluator for short-term gains. This may lead to the incorrect conclusion that a fellow is making appropriate progress and leave little opportunity for rectification of his or her weakness. The true purpose of training may not be achieved in that case. This is more likely if the summative evaluation of curricular milestones is taken by a few evaluators. A clinical competency committee that includes core teaching faculty and representatives from the different disciplines should be involved in making decisions on progression through training. In addition to faculty evaluation, assessments from patients, nurses, and staff should be considered in competency-based evaluation. The trainees also might benefit from a structured mentoring program, where confidentiality between mentor and trainee would allow trainees to feel more comfortable expressing their weaknesses and seeking suggestions to fix them. It should be ensured that ethnic minorities, women, and international medical graduates receive mentoring and support that is empathetic and sensitive to their needs.
One of the major threats to the validity of milestone-based training is evaluator bias. The supervising faculty needs to be trained on the use of milestones in competency assessment with standardized criteria. Frequent formative feedback should be provided on the basis of direct observation of performance and specific behaviors that are expected should be explicitly stated. Finding the right balance between direct supervision and providing autonomy to the fellow is crucial.
It is essential that the milestones also incorporate skills required for the next generation of health care delivery, including leadership training, respecting the skills of other practitioners, resource management, health policy and regulation, risk management, relationship with industry, time management, stress management, conflict management, and providing performance feedback to peers and juniors. Milestones are unlikely to replace board examinations; however, they may be a good starting point for an innovative design of board examinations. The next phase of competency-based assessment will probably involve short-track pathways for suitably competent fellows. Some would argue that a 3-year training period is necessary for sufficient exposure to diverse aspects of cardiology, for adequate longitudinal care of a panel of patients, and to refine the skills needed to care for these patients. A 2-year short-track pathway may mitigate the nation’s shortage of cardiologists and allow for better utilization of the available resources.
As we shift toward milestone-based evaluation in cardiology fellowship training, we need to actively participate with the ACGME to improve the new evaluation system before high-stakes decisions are based upon it.
- American College of Cardiology Foundation
- ↵The Internal Medicine Subspecialty Milestones Project. Available at: https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineSubspecialtyMilestones.pdf. Accessed July 29, 2014.