A Milestone in the Milestones Movement: the JGME Milestones Supplement

摘要

Milestone: 1. A stone marker set up on a roadside to indicate the distance in miles from a given point. 2. An important event, as in a person's career, the history of a nation, or the advancement of knowledge in a field; a turning point.1;Background The United States health care system and graduate medical education are undergoing intense and inter-dependent transformation. The Institute of Medicine's (IOM) 2001 Crossing the Quality Chasm report2 argued that the U.S. health care delivery system failed to provide consistent, high quality medical care and was poorly organized to meet the changing public health landscape. In response, health care systems, providers, and payers have embarked on a journey to reach the “Triple Aims” of better care for individuals, better health for populations, and reducing per capita health care costs. Reforms underway in health care payment structures will likely have major, not yet fully understood effects on U.S. health care and graduate medical education (GME).3 In 1997 the Accreditation Council for Graduate Medicine Education (ACGME) initiated the Outcome Project. Paralleling the IOM focus on quality and safety, the Outcome Project shifted GME's focus from processes towards trainee and program performance. During this period numerous other forces, including duty hour limits and new technologies, shaped GME. As a result, GME training has become increasingly complex in content, program requirements, and assessment modalities. These developments have forced programs to greatly expand administration supports. The administrative burden on designated institutional officials, program directors, and faculty may threaten teaching efforts and resident learning. The administrative load has been compounded by increased financial burdens on institutions during this era of health care reform; these are likely to worsen if funding for GME declines. In response to this “perfect storm,” GME educators and researchers created new paradigms to frame training with the goal of graduating physicians able to provide high quality, safe, and cost-effective care. The Outcome Project introduced specialty-defined physician competencies aggregated into 6 general areas, which recognized that physician competence entails multiple domains.4 Identification of specialty-specific competencies spurred development of tools to measure them, which has met with mixed success.5 As the number of subcompetencies expanded, each requiring assessment, efforts to describe the typical progression of physician competence led to the concepts of educational milestones and entrustable professional activities (EPAs). ten Cate and Scheele advanced EPAs as a way to describe the essential characteristics of independent practitioners, which could guide decisions regarding resident independence.6,7 A key tenet of competency-based education is that proficiency progresses on a continuum within each specialty-specific domain.4 As a result several specialties have developed educational milestones to create a blueprint for trainee progress during residency.8 In the most basic explanation, the milestones add a timeline and benchmarks to resident progression towards independent practice. In assigning a timeline to the milestones, some specialties have employed a framework for acquisition of expertise, such as the 5-level Dreyfus and Dreyfus model (novice, beginner, competent, proficient, expert).9,10 Others have determined the point during residency at which an individual milestone should usually be achieved.9,10;Milestones Development In July 2013, the next phase of the ACGME Outcome Project begins for 7 specialties through the Next Accreditation System (NAS).11 These NAS Phase I specialties have modified existing milestones or created new milestones to fit the NAS reporting requirements, which include reporting of performance every 6?months. Reporting requirements will be implemented for Phase II specialties in July 2014.11 As originally conceived, milesto