Witteles and Verghese Take on the ACGME Milestone Program

When the Accreditation Council for Graduate Medical Education (ACGME) makes a major change to the way trainees are assessed throughout residency and fellowship, the onus of implementation falls to the nation’s residency and fellowship training programs, especially their directors. Within each such program, the burden most clearly affects the Clinical Competency Committee, a group of faculty who assess trainees twice each year. That burden was dramatically increased in 2013-4 when the ACGME went to a “Milestones-based” system of assessment.

In the September 26, 2016, issue of JAMA Internal Medicine, Ronald Witteles, MD, and Abraham Verghese, MD, suggested that the ACGME’s Milestones might cause a revolt.

The problem arises when implementing assessments by Milestones. By the authors’ reckoning, each member of the Clinical Competency Committee would need to spend at a minimum about seven weeks each year just assessing trainees to be true to the requirements. This estimate is based on 120 Stanford trainees being graded on 22 Milestones, each of which contains up to 18 performance descriptors, using a scale of 1 to 9, and doing it two times each year. While suggesting that more time would be better, they nevertheless used three minutes per Milestone to arrive at the total time each Committee member would need to spend.

Witteles and Verghese point out that training programs themselves are assessed based on the performance of their trainees, creating a “perverse incentive” for Committee members to check all the right boxes for each trainee, guaranteeing that both the trainees and the program will be found to be of high quality.

A comparison was made with the recent debacle following introduction of the Maintenance of Certification program of the American Board of Internal Medicine (ABIM), wherein a similar supposedly benign change to the way things were done became a nightmare for clinicians, who quickly and loudly voiced their displeasure. In the case of the ABIM, changes were made as a result. After three years of the Milestone program, Witteles and Verghese describe it as a millstone and conclude that the ACGME should consider their promise to help training program directors “mentor residents rather than manage programs.”

Read the full viewpoint here.