The Next Fellowship Program: Fulfilling the ACGME NAS

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) launched the Outcomes Project. This initiative reframed and codified postgraduate medical education in the United States by shifting the focus away from educational processes and towards educational outcomes. Residency and fellowship programs would no longer serve as structured apprenticeships, but instead develop trainees along six core competencies. The ACGME identified Medical Knowledge, Patient Care, Practice-Based Learning and Improvement, Systems-based Practice, Interpersonal and Communication Skills, and Professionalism as key educational domains. This structure ensured that trainees develop the requisite skill sets through achieving competency in meaningful pre-defined areas.

The Outcomes Project was followed up by the unveiling of the Milestone Project in 2012. The ACGME sought to extend the objectives of competency-based training to a system that tracks progress along a set of developmental milestones. Along with the Next Accreditation System (NAS), these initiatives introduced a new language into residency and fellowship training, with terms like Reporting Milestones, Curricular Milestones, Entrustable Professional Activities (EPAs), and Clinical Competency Committees (CCCs). Reporting Milestones are 23 context nonspecific markers of a trainee’s development in aspects of the 6 core competencies, and mark the growth of an individual trainee. Curricular Milestones are educational goals in terms of knowledge, skills, and behavior within the context of a discipline and structure of a training program. EPAs are training activities, such as management of a hemodialysis population, evaluation of inpatient consultations, or engaging in a multi-disciplinary transplant service, that provide opportunities for observation and assessment of trainees skills across multiple competencies. These EPAs inform growth along the Curricular Milestones, which in turn informs development along the Reporting Milestones. And finally, the CCC is a group of faculty members, trained in milestone assessment, which is tasked with charting trainee’s progress along the milestones at discreet time points during the training program. Together, these elements create a process of ensuring trainees achieve requisite skills to practice independently in a field of medicine.

In a recently published article in AJKD, Yuan et al describe the implementation of the Milestone Project in the Nephrology Fellowship Training Program at Walter Reed National Military Medical Center. They demonstrate how clinical activities (identified as EPAs), including dialysis emergency response and clinic management, are objectively assessed with forms and tools that clearly and directly map to programmatic Curricular Milestones. These Nephrology-specific skills are then re-mapped to the context nonspecific Reporting Milestones, which serve as data for the CCC to determine the progress of individual trainees over a 2-year training experience towards independence. The authors provide assessment tools and mapping guides to demonstrate how multiple evaluations can provide a robust picture of a trainee’s performance in the Curricular Milestones, and how a CCC can then bundle this progress in Curricular Milestones to determine growth along the Reporting Milestones. Furthermore, this process facilitates the provision of constructive feedback, remediation, and individualized learning plans.

Yuan et al demonstrate the how the dizzying expectations of the Milestone Project and NAS can yield a thoughtful, organized, and pragmatic approach to ensuring our trainees reach the aptitude we expect from practicing nephrologists. Through frequent assessments of progress and ascertainment of targeted outcomes along the training pathway, underperforming trainees can be identified and remediated. Progressing fellows can be recognized when they achieve the skills for independent and unsupervised practice. And fellows who demonstrate aspirational skills can be directed towards higher levels of accomplishment. In the end, a structured program that monitors progress and ensures competency for independent practice will yield a training system that fulfills our training mission.

Scott J. Gilbert, MD
Fellowship Director in Nephrology, Tufts Medical Center
AJKD Education Editor
Associate Professor of Medicine, Tufts University School of Medicine

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