ACGME Milestones or Millstones?
Are residency milestone requirements tools for standardizing knowledge and skills to ensure minimum standards or are they meaningless metrics and burdensome documentation for both trainees and attendings?
The Accreditation Council for Graduate Medical Education (ACGME) requires that all residency programs develop milestones that track progress across the years of training. The milestones consist of standards, such as minimum numbers of a procedure, which are to be part of a resident's learning portfolio, along with more traditional subjective assessments of competency from attendings who teach and work with the residents. Having milestone requirements is supposed to minimize the sometimes large inconsistencies between residency program experiences and expectations for residents.
Radiology Firing Line podcast host Saurabh Jha, MD, moderates a friendly debate between Mark Sellmyer, MD, PhD, current radiology chief resident at the Hospital of the University of Pennsylvania, and Phil Mulugeta, MD, former chief resident and current nuclear radiology fellow at the same institution.
Their conversation raises many unanswered (and possibly unanswerable) questions about milestones. Are the milestones realistic? Are the current minimum standards appropriate and meaningful? And who decides? Can a threshold number of diagnostic imaging studies interpreted be used, even in part, to gauge competency?
As a chest radiologist, I've had residents interpret a mere ten chest radiographs, and I can tell that they "get it," both with respect to perception and interpretation. Then there are other residents who, after 100 or more radiographs, continue to struggle with perception but have no such difficulty with CT. For these residents, minimal competence may take longer to achieve even if they have met some arbitrary-seeming threshold number of chest radiograph interpretation. Do checklists make sense when training follows an apprenticeship model?
Judgment does not lend itself well to metrics-based assessment and is not a quantifiable, observable behavior. Yet judgment is arguably the most critical skill any physician can possess. Sure, you can simulate scenarios in a test environment, but nothing matches real-life trying situations to test someone's mettle. How should deficiencies in achieving milestones be viewed at the level of individual residency programs? Should they be seen as opportunities for corrective measures to be developed, applied, and tested? Or would the existence of some residency programs be in jeopardy?
These and many more questions are being asked by residents and attendings everywhere. While we wait indefinitely for answers, we all have little choice but to do our part to comply with ACGME milestone documentation requirements, and residency program directors bear the yeoman's share of this thankless task. Hopefully, based on feedback from residency programs, the milestones will improve to become a more meaningful tool to ensure we continue to graduate skilled, competent radiologists.