Leo Sher, M.D.

The graduate medical education in the United States has a long and interesting history. In 1840s, there were about 30 medical schools in the US. Seven of them were located in New York (1). In 1847, the American Medical Association (AMA) was formed. The primary task of the AMA was to raise ethical standards in the practice of medicine. In 1876, the Association of American Medical Colleges (AAMC) was created. Around 1900, the AMA began rating medical schools.

In 1910, Abraham Flexner (1866-1959), an educator working for the Carnegie Foundation, published the Flexner Report, which assessed the quality of education in medical schools in North America (1-3). Flexner visited all 155 medical schools in the US and Canada.His general impression was that “Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated.” Flexner recommended to a) reduce the number of medical schools (from 155 to 31) and inadequately trained physicians; b) increase the prerequisites to enter medical training; c) train physicians to work in a scientific manner and involve medical faculty in scientific research; d) give medical schools control of clinical training in hospitals; and e) toughen state regulation of medical licensure. The Flexner Report is well-known nowadays because it resulted in producing a single model of medical education, characterized by a philosophy that has largely survived to the present day.

In 1928, AMA published the “Essentials of Approved Residencies and Fellowships” (1). It established the principles for residency programs. During the following decades, various medical boards and other organizations were created to oversee and improve medical education and training. In 1965, the US Congress approved the Medicare Bill. Medicare funds the majority of residency training in the US. With the creation of Medicare support, graduate medical education was raised to the level of public policy.

Currently, the Accreditation Council for Graduate Medical Education (ACGME) is the organization responsible for accrediting most of graduate medical training programs (i.e., internships, residencies, and fellowships) for physicians in the United States (1,4,5). It is a non-profit private board that evaluates and accredits medical residency and internship programs. The ACGME was created in 1981 and was preceded by the Liaison Committee for Graduate Medical Education, which was founded in 1972. When the ACGME was launched in 1981, the graduate medical education environment was facing two major problems: variability in the quality and features of resident education and the developing formalization of subspecialty training. The ACGME claims that it was able to improve education of medical trainees. At the same time, administrative burdens have grown. The ACGME asserts that it serves the society by setting and administering standards that rule the specialty education of future generations of physicians.

In 1999, ACGME introduced the six domains of clinical competency to the profession (6):
• Patient Care
• Medical Knowledge
• Practice Based Learning and Improvement
• Systems Based Practice
• Professionalism
• Interpersonal Skills and Communication

In 2009, the ACGME began a multiyear process of restructuring its accreditation system to be based on educational outcomes in these competencies (4). The result of this effort is the Next Accreditation System (NAS), an outcomes-based accreditation process through which the physicians of tomorrow will be evaluated for their competency in performing the tasks necessary for clinical practice in the 21st century. The aims of the NAS are threefold: to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century, to accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes, and to reduce the burden associated with the current structure. The ACGME states that key benefits of the NAS include the creation of a national framework for assessment that includes comparison data, reduction in the burden associated with the current process-based accreditation system, the opportunity for residents to learn in innovative programs, and enhanced resident education in quality, patient safety, and the new competencies.

Programs in the NAS will submit composite milestone data on their residents every 6 months, synchronized with residents’ semiannual evaluations. The data submitted to the ACGME will consist of 30 to 36 dimensions that represent the consensus of the assessment committee on the educational achievements of residents.
 
As the ACGME began to move toward continuous accreditation, specialty groups developed outcomes-based milestones as a framework for determining resident and fellow performance within the six ACGME Core Competencies (4,7.8). 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. Faculty overseers, particularly those supervising clinical work, will evaluate many Milestones.

A general interpretation of levels for psychiatry is below:
•    Has Not Achieved Level 1: The resident does not demonstrate the Milestones expected of an incoming resident.
•    Level 1: The resident demonstrates Milestones expected of an incoming resident.
•    Level 2: The resident is advancing and demonstrates additional Milestones, but is not yet performing at a midresidency level.
•    Level 3: The resident continues to advance and demonstrate additional Milestones; the resident demonstrates the majority of Milestones targeted for residency in this subcompetency.
•    Level 4: The resident has advanced so that he or she now substantially demonstrates the Milestones targeted for residency. This level is designed as the graduation target.
•    Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating aspirational goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.
Levels 2, 3, 4 do not necessarily correlate to PGY 2, 3, 4.

The Milestones are designed to help all residencies and fellowships produce very capable physicians to meet the health care needs of the public. The new system will allow for constant watching of programs and increasing of site visit cycles. Residents’/fellows’ performance on the Milestones will be a foundation of specialty-specific data for the specialty Review Committees to use in evaluating the quality of residency and fellowship programs and for assisting improvements to program curricula and resident performance.

References
1.    Taradejna C.. ACGME History. History of medical education accreditation. http://www.acgme.org/acgmeweb/tabid/122/About/ACGMEHistory.aspx  Accessed: May 16, 2014.
2.    Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4, New York City: The Carnegie Foundation for the Advancement of Teaching, 1910.
3.    Cox M, Irby DM, Cooke M, Irby DM, Sullivan W, Ludmerer KM. American Medical Education 100 Years after the Flexner Report. New Engl J Med 2006;355(13):1339–1344.
4.    Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system–rationale and benefits. N Engl J Med 2012;366(11):1051-6.
5.    ACGME at a glance. http://www.acgme.org/acgmeweb/tabid/120/About/ACGMEataGlance.aspx  Accessed: May 16, 2014
6.    Swing SR, Clyman SG, Holmboe ES, Williams RG. Advancing resident assessment in graduate medical education. J Grad Med Educ 2009;1:278-86.
7.    Thomas CR. Educational milestone development for psychiatry. J Grad Med Educ. 2014;6(1 Suppl 1):281-3.
8.    No authors listed. The psychiatry milestone project. J Grad Med Educ. 2014 Mar;6(1 Suppl 1):284-304.