1. Milestones
and
EPAs
The definition of expected
outcomes or competencies

2. Milestones
 A significant point in development that
identifies the discrete knowledge, skills, and
attitudes expected of learners as they
progress through training.
 Milestones should enable the trainee, program
and the certification board to know an
individuals trajectory of competency
acquisition.

3. Dreyfus & Dreyfus Development Model
PGY3 Expert/
Master
PGY1 Proficient
MS4 Competent
MS3
Advanced Beginner
Novice
Time, Practice, Experience
Dreyfus SE and Dreyfus HL. A 1980
Carraccio CL et al. Acad Med 2008;83:761-7

4. Progression Varies by Trainee & Context
PGY1
MS4
PGY3 PGY3 Expert/
PGY1 Master
PGY1 Proficient
MS4
MS4 Competent
MS3
Advanced Beginner
Novice
Time, Practice, Experience
Dreyfus SE and Dreyfus HL. A 1980
Carraccio CL et al. Acad Med 2008;83:761-7

5. The Internal Medicine Milestones
 142 milestones organized by competency
and competency sub-divisions
 Framed in behavioral terms (Competence is
observed in practice!) that define
knowledge, skills, attitudes and behaviors
 Linked with potential assessment tools
 Published in 2009

6. Patient Care
ACGME Developmental Milestones Approximate Assessment
Competency Informing Time Frame Methods/Tools
ACGME Competencies Trainee to
Achieve
Stage
Clinical skills and Historical Data Gathering Standardized
reasoning 1. Acquire accurate and relevant history 6 months patient
 Manages from the patient in an efficiently Direct Observation
patients using customized, prioritized, and hypothesis Simulation
clinical skills of driven fashion
interviewing and 2. Seek and obtain appropriate, verified, 9 months
physical and prioritized data from secondary
examination sources (e.g. family, records, pharmacy)
3. Obtain relevant historical subtleties that
inform and prioritize both differential 18 months
diagnoses and diagnostic plans,
including sensitive, complicated, and
detailed information that may not often
be volunteered by the patient
RRC
sub-bullet

7. Milestones Benefits
 Provide the learner with a clear path of
progression
• There are no surprises
 Allow for rich formative feedback. Learners
know where they are and where they need to
go
 Define specific behaviors that can focus
assessment

8. Milestones Criticisms
 Milestones are reductionistic
 Checking off a milestones list does not equal
competent practice in a highly complex health
care environment
 There are 142 curricular milestones
Programs can not assess them all
• Even over three years!

9. Milestone Challenges
 Utilize the milestones to develop meaningful
assessment and evaluation.
• Generate data that enables attestation of
desired competence.
• What the government, public and the
profession trust physicians are capable of
doing
 Evolve the milestones to be more manageable
that allows attestation of competence in desired
outcomes.

10. ACGME Accreditation Milestones
 Will serve as one of nine sets of data that
ACGME will use when accrediting programs
 Will allow ACGME to track the development
of desired competence at the program level
 Milestones reporting will occur twice per year
and will begin in 2013

11. ACGME Accreditation Internal
Medicine Milestones
 Discrete developmental narratives describing
the development of competence in the
learner in each of the six ACGME general
competencies
 Define stages of development (informed by
assessment data) that provide the framework
for making judgment/attestation of
competence
 23 narrative milestones streams

13. ®
Entrustment/Entrustable
Professional Activities (EPAs)
A framework for work-based
assessment?
© 2008, 2009 American Board of Internal Medicine
All rights reserved.

14. Assessment/Evaluation Challenges
 Ensure that assessment documents
competence in those activities required to
achieve the desired outcome of training
• Assessment that is meaningful!
• Assessment that is manageable!

15. Entrustable Professional Activities
 EPAs represent the routine professional-life
activities of physicians based on their specialty
and subspecialty
 The concept of “entrustable” means:
• „„a practitioner has demonstrated the
necessary knowledge, skills and attitudes to
be trusted to independently perform this
activity.‟‟1
1Ten Cate O. Acad Med. 2007;82(6):542–547.

16. An Entrustable Professional Activity
 Part of essential work for a qualified professional
 Requires specific knowledge, skill, attitude
 Acquired through training
 Leads to recognized output
 Observable and measureable, leading to a
conclusion
 Reflects the competencies expected
 EPA‟s together constitute the core of the profession
ten Cate et al.
Acad Med 2007
16

17. Training and Safe Patient Care
Trainee performance* X
Appropriate level of supervision**
Must = Safe, effective patient-centered care
* a function of level of competence in context
**a function of attending competence in context

18. “Entrustment in Medical Education”
 Focused assessments around what faculty
and training programs already “entrust”
trainees to do?
 Reflects the most important outcome of
training: a trainee‟s readiness to bear
professional responsibility”
 Enables work-based assessment focusing
on demonstrating competence in desired
outcomes of training.

19. Thank You