Pediatrics Milestones: A Developmental Approach to the Competencies
Article Outline
ABP, American Board of Pediatrics, ACGME, Accreditation Council for Graduate Medical Education, APPD, Association of Pediatric Program Directors, GME, Graduate medical education, LEARN, Longitudinal Educational Assessment and Research Network, UME, Undergraduate medical education
In 2009, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP) partnered to create the Pediatric Milestone Project. One of the goals of this project was to reframe the 6 competencies in the context of the specialty, identifying markers of achievement (ie, milestones) along the path of residency training. They invited Carol Carraccio, MD, to be the project leader, and her first task was to establish an Advisory Board and a Working Group. Advisory Board members were recruited from the parent organizations as well as from the pool of national leaders in medical education, both from within and outside of pediatrics. The selected Working Group, composed of members of the Association of Pediatric Program Directors (APPD), one member of the Medicine Pediatrics Program Directors' Association, two representatives of the ACGME, and a resident member, was charged with the following tasks: (1) redefine the competencies within the context of pediatrics; (2) set performance standards by level of training for achievement of the milestones; and (3) identify tools that could be embraced by the whole of the pediatric community to assess performance.
The purpose of this report is to briefly describe the process used by the Working Group to accomplish the first charge of developing the milestones. We highlight some of the key lessons learned throughout the past year and outline future steps on the path to completion of our charge. We hope that other specialty groups will find this approach useful in their own work toward the ultimate goal of the Milestone Project: the ability to assess achievement of educational/curricular goals and program effectiveness.
The Process
The Working Group convened in March 2009 with the goal of creating a conceptual framework to guide the development of the pediatric milestones. Those discussions led to a set of guiding principles and conceptual considerations. This effort was an iterative process that took 2 months of discourse between the Working Group and Advisory Group members; the documents served to keep us on track as we traversed uncharted terrain. We agreed that the vision of this work is to meet societal needs for quality patient care through better education and training by linking educational outcome measures to patient care outcomes. A guiding principle for the final product was that it needed to be grounded in the literature with an appreciation of the evolving evidence in learner assessment. Toward that end, members of the Working Group systematically examined the literature, reviewing hundreds of papers spanning a number of disciplines, to best frame the developmental ontogeny of the competencies.
Another guiding principle was that the ACGME competencies are necessary, but might not be sufficient, in defining milestones for the professional formation of pediatricians. Toward that end, at the 2009 spring APPD meeting, we introduced the project and collected written feedback from attendees. We gained specific input regarding which implicit subcompetencies were critical and needed to be made explicit. The themes that emerged from this feedback were related to personal and professional development; these additional elements were added to the existing ACGME subcompetencies.
One of the conceptual considerations developed by the Working Group was that the milestones needed to be constructed as descriptions of behaviors that demonstrate progression along the continuum from undergraduate medical education (UME) through practice, with an emphasis on the years of graduate medical education (GME). Thus, for each subcompetency, the primary author constructed a series of milestones, each describing the behaviors that signify progression of knowledge, skills, and attitudes gleaned from the literature. This developmental approach framed the draft documents that the Working Group vetted during semi-weekly conference calls over the past year. The Advisory Board provided ongoing feedback and advice along the way.
Lessons Learned
Several overarching themes emerged as we tackled the work of understanding the developmental ontogeny of the competencies and subcompetencies. We first recognized several common pathways to the developmental progression of many of the subcompetencies. First, physician development for many subcompetencies progresses from dependence on external prompts, consequences, or influences, such as oversight and regulation, to a more intrinsically driven and self-motivated and regulated process, involving learner reflection for the purpose of improvement.1 Second, part of the developmental process of a physician involves expansion of the perspective of “patients” as “individual” patients and families to the understanding and need to embrace the community and populations of patients at large and, ultimately, the entire system of care. Third, for many of the subcompetencies, the physician's development evolves from a model of self-contained practice to an increased awareness of, and attention to, the roles and interdependence of the various health care professionals. This leads to the need to optimize partnerships and teams.2, 3 Fourth, development along several subcompetencies involves progress from knowledge to competence (ie, the ability to demonstrate a skill in context), to capability (ie, the ability to adapt competence to a variety of contexts), and finally escalating to the ability to cope with ambiguity.4
One of the most important lessons learned thus far in the Working Group's writing is that many developed milestones have shared elements of performance, because of the overlapping and integrated nature of the competencies themselves. This is not surprising, given our current understanding of the competencies as inseparable and clustered variables, framed in the context of clinical care. The complexity of assessing the competencies has led educators to break them down into subcompetencies, which are easier to assess. However, ongoing efforts to design tools to assess learners' ability to integrate the competencies as they would in practice will ultimately serve to measure more meaningful educational and healthcare outcomes.5 Ultimately, professional development is inextricably linked to the integration of all of the competencies.
Finally, we appreciate that although the medical literature may offer evidence to inform our understanding of the developmental progression of physician competence, we often found rich resources within the health science and social science research literature. As future groups begin to construct their own milestones, they may find it beneficial to look beyond the medical literature databases to inform their understanding.
Future Steps
Our draft of the pediatric milestones is the first step, and will be followed by engaging medical education assessment experts and content experts to assist us in refining our work by providing rigorous editing. In addition, we intend to share our pediatric milestones draft with other specialty groups who are embarking on the process of milestone development for their specialty. We hope to learn from their adoption and adaptation of the milestones to inform future iterations of our milestones and theirs. We also look forward to incorporating the input from key stakeholders, including program directors, faculty, learners, and the public, as well as from the ACGME and ABP, the organizations that initiated this work.
Another opportunity to inform future iterations of the milestones will come from the partnership of the Initiative for Innovation in Pediatric Education with the APPD in bringing the Longitudinal Educational Assessment and Research Network (LEARN) into its first phase of development. As a resource to support the work of research collaboratives, LEARN will be dedicated to studying outcomes of educational innovations. As such, LEARN will help us test and translate the milestones, propelling the thoughts that we developed in vitro into the in vivo clinical world.
Our goals in studying the milestones are threefold. First, we wish to engage medical educators and researchers in evaluating the milestones to establish their validity and reliability. Second, once reliability and validity have been established, we aim to develop performance standards to identify the key transition points for residents along their developmental continuum. These cutpoints will allow us to focus on ranges of time during which most learners will achieve a given milestone. Conversely, failure to meet the transition points will serve as an objective measure to institute remediation of learners in difficulty. We hope that the understanding of these thresholds will function in much the same way as a developmental screen, identifying children at risk for developmental delay (eg, not walking by age 18 months) and requiring further assessment and possible intervention. Third, as a far-reaching goal, we hope that improving our measurement of performance in and of itself might help move the developmental continuum in a directed fashion, allowing earlier and more directed progression to the desired outcomes. With the alignment of outcomes to curricular goals, assessment can provide more meaningful feedback to individual learners and, by informing local and national curricula, better meet the needs of learners.
Because the milestones target UME as well as GME, we also have the opportunity to identify the knowledge, skills, and attitudes that medical students should bring to GME, granting us the opportunity to build on a solid foundation.
In summary, our overarching goal is to ensure that this comprehensive process will make assessment and feedback to individual trainees more meaningful and that trainee assessment will yield valuable evaluation of training programs, ultimately contributing to improved quality of care for our patients.
Appendix.
Additional members of the Pediatric Milestone Project Working Group include Ann Burke, MD, Carol Carraccio, MD, MA, Susan Guralnick, MD, Lisa Johnson, MBA, Stephen Ludwig, MD, Daniel Schumacher, MD, and Jerry Vasilias, PhD.
References
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- The role of teamwork in the professional education of physicians: current status and assessment recommendations. Joint Comm J Qual Patient Safe. 2005;31:185–202
- . Complexity science: the challenge of complexity in health care. BMJ. 2001;323:625–628
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PII: S0022-3476(10)00573-1
doi:10.1016/j.jpeds.2010.07.001
© 2010 Mosby, Inc. All rights reserved.
