In 1999, the Accreditation Council for Graduate Medical Education (ACGME) selected and endorsed a set of competencies to help define the foundational skills every practicing physician should possess. These six ACGME Core Competencies, as they are called, were developed as a way to shape and evaluate the education of residents. In this way, ACGME aimed to create educational programs that reflect skills and attributes that are directly relevant to patient care, preparing residents for a successful daily practice. More recently, the American Board of Medical Specialties (ABMS) has integrated the ACGME core competencies into the Maintenance of Certification (MOC) program.

In this series of blog posts, we will offer a detailed overview of each of the ACGME Core Competencies. We will also outline the milestones associated with learning and fulfilling ACGME Core Competencies in different medical specialties.

What Are the ACGME Core Competencies?

ACGME Core Competencies measure a physician’s ability to administer a high level of care to diagnose and treat illness, offer and implement strategies to continuously improve patient health and wellness, offer advice and resources to prevent disease in patients, and provide not only physical treatment, but also emotional support as the physician cares for patients and interacts with patients’ families and support systems.

The six ACGME Core Competencies are as follows:

  • Practice-Based Learning and Improvement
  • Patient Care and Procedural Skills
  • Systems-Based Practice
  • Medical Knowledge
  • Interpersonal and Communication Skills
  • Professionalism

Beyond the ACGME Core Competencies: Milestones and EPAs

Milestones

More recently, the ACGME has worked with ABMS member boards to develop specific milestones for each specialty that support the overarching 6 competencies. Milestones provide a framework by which residents and later, physicians, can be evaluated, using key elements of each competency that a physician is expected to demonstrate. By determining the knowledge, skills, and other attributes that attend each ACGME Core Competency and its subcompetencies, the ACGME can quantify not only the readiness of residents, but the efficacy of medical training programs.

The ACGME defines milestones as follows:

“… a milestone is a significant point in development. For accreditation purposes, the Milestones are competency-based developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties.”

Milestones are specialty-specific. Although some milestones may apply to several specialties, most specialties define their own set of milestones to assess competency within that area of medicine. As an example, the following is a list of the milestones in Internal Medicine:

  1. Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s).
  2. Develops and achieves comprehensive management plan for each patient.
  3. Manages patients with progressive responsibility and independence.
  4. Skill in performing procedures.
  5. Requests and provides consultative care.
  6. Clinical knowledge
  7. Knowledge of diagnostic testing and procedures.
  8. Works effectively within an interprofessional team (e.g. peers, consultants, nursing, ancillary professionals and other support personnel).
  9. Recognizes system error and advocates for system improvement.
  10. Identifies forces that impact the cost of health care, and advocates for, and practices cost-effective care.
  11. Transitions patients effectively within and across health delivery systems.
  12. Monitors practice with a goal for improvement.
  13. Learns and improves via performance audit.
  14. Learns and improves via feedback.
  15. Learns and improves at the point of care.
  16. Has professional and respectful interactions with patients, caregivers and members of the interprofessional team (e.g. peers, consultants, nursing, ancillary professionals and support personnel).
  17. Accepts responsibility and follows through on tasks.
  18. Responds to each patient’s unique characteristics and needs.
  19. Exhibits integrity and ethical behavior in professional conduct.
  20. Communicates effectively with patients and caregivers.
  21. Communicates effectively in interprofessional teams (e.g. peers, consultants, nursing, ancillary professionals and other support personnel).
  22. Appropriate utilization and completion of health records.

The milestones are assessed along a scale from “not yet assessable” to “aspirational.” Each stage on this scale measures competence assuming the residents will begin at one end of the scale and, as they acquire further knowledge and training, move up the scale to the final level.

At the low end of the scale, a resident may exhibit “critical deficiencies,” which means the learner behaviors indicate a significant lack in performance, and are not within the spectrum of developing competence. As a resident moves upward through the scale, he or she may exhibit the behaviors of an early learner, then an advanced learner who displays improvement in ability.

When a resident is deemed “ready for unsupervised practice,” he or she has demonstrated abilities that match a typical practicing physician, one who could practice without continuous guidance and supervision. Although this is obviously the end goal of any medical-training program, some residents may demonstrate this level of competency in milestones throughout his or her training. At the top of this scale, an “aspirational” resident is one who has advanced beyond the milestones and can be considered an expert, or even a role model. Understandably, the “aspirational” level is reserved for exemplary residents.

But more change is on the way.

Entrustable Professional Activities

The ACGME is now laying the groundwork to move residency programs toward using Entrustable Professional Activities (EPAs) as a core part of resident competency assessment. While the milestones might be somewhat abstract and require assumptions about knowledge, the EPAs are all supposed to be observable activities. For example, an EPA for a pediatric hospitalist might be: serve as the primary admitting pediatrician for previously well children suffering from common acute problems and for a family medicine trainee might include “Evaluate and manage undifferentiated symptoms and complex conditions.” Boards, societies, and education researchers are still developing specialty-specific EPAs, and these are not yet widely in use in resident evaluation.

For Graduate Medical Education programs (GME), the ACGME Core Competencies milestones provide explicit, structured information that can direct curriculum and enhance assessment for residents and fellows. By using the data from milestones, GME programs can pinpoint potential areas of difficulty in medical practice, and beef up the material around those areas at the educational level. Trainees’ ability to meet these milestones can be traced back to their education in the ACGME Core Competencies. In this way, the ACGME Core Competencies milestones measure more than just resident and fellow performance; they assess the quality of medical training and education as a whole.