ACGMElogoConfusion, acronyms, and big words that seem to all mean the same thing – these were the general thoughts and sentiments that I had regarding competencies, milestones, and resident assessment in general. I am sure I am not alone. At this point near the end of August 2013, most of the EM residents have heard the term EM Milestones at least once… if not on a daily basis. Many probably don’t know what they are nor how they came about. One day we are talking about competencies, and now we are talking about milestones! So I looked into this more. Bottom line – it all comes down to how we are assessing our residents going through EM education.


In 1999, ACGME introduced the 6 domains of clinical competency that are core for each physician regardless of specialty.


In 2009, the ACGME began the process of overhauling the accreditation system to be based on educational outcomes in these 6 competencies – known as the Next Accreditation System. Competencies would be assigned to observable behaviors known as “milestones” [1].


Unlike the prior high-level explanations of competencies, milestones are more clearly defined and behavior-based, with the hope that residents know exactly what knowledge, skills, and performance are expected of them throughout residency.

“A milestone is an observable behavior that falls within five levels of proficiency from entry Level 1 – medical school graduate, to Level 5 – level expected to be achieved after years of clinical practice. Level 4 is the behavior expected of a graduating EM resident.” [2]

Milestones are transparent, competency-based, developmental outcome expectations that can be demonstrated progressively by residents and fellows from the beginning of residency through graduation to unsupervised practice. It is assumed that residents will naturally evolve in their education and acquire particular knowledge and skills with each passing year. If anything, the system forgives interns for their lack of knowledge and skills at the beginning of their training. And it also recognizes that senior residents should be accomplished and skilled in tasks such as resuscitation and ultrasound.

There were originally 6 competencies, from which there are now 23 milestones, with at least 5 levels of behaviors to measure for each milestone, with most milestones having multiple behaviors to assess for in each level. Milestone #1 (PC1 Emergency Stabilization) has within it 11 behaviors between Level 1 and 5. This is a lot of behavior that will be assessed for in residents!

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EVERY specialty is undergoing this process of examination through their respective Milestone Working Group in order to create their own specialty specific milestones. EM is one of 7 other specialties (Radiology, Internal Medicine, Neurosurgery, Orthopedic Surgery, Pediatrics, Urology) that started the Next Accreditation System (NAS) July 2013. The other specialties will follow in July 2014. Going through the ACGME website will allow you to see which specialties have already gone through the exercise, and what their milestones are. It is interesting to compare and contrast each specialty and acknowledge the nuances of the differences and similarities between us.

How are Milestones different from Competencies?

Rather than ask how they are different, milestones can be thought of as the next generation of competencies, or the natural evolution of competencies. Milestones “describes competencies more specifically and identifies specialty-specific knowledge, skills, attitudes, and behaviors (KSABs) that can be used as outcome measures within the general competencies.”[3] By creating the Milestone Project, ACGME has allowed for each specialty to identify behaviors unique to their own practice that allows for their residents to address the competencies. Finally there is acknowledgement that the skills to becoming a great psychiatrist are different than the skills needed to becoming a great EM physician. A great example is the widespread use of ultrasound in EM education that is unique to our specialty [4].

What may be coming in the future?

  • Level 1 milestones will be the domain of medical student (undergraduate) education. This provides medical students more guidance as to the basic knowledge and skill set that would be required of them prior to entering residency. This means that there is an expected eventual role for medical schools to play in the milestone game.
  • Certain Level 4 and 5 milestones may be considered the entry point into being able to practice independently in the Emergency Department.
  • Level 5 milestones, typically describing the performance of someone who has been in practice for several years, can help guide already practicing physicians on how to maintain basic certification, licenses, and knowledge that will drive lifelong learning.
  • CMEs, national/international conferences, and perhaps credentialing at job sites may have to be reconsidered given these changes.

 Additional Readings:

Disclaimer: I was not involved in the process of EM Milestone development. Please feel free to correct or supplement any of the information presented, especially if you are a subject matter expert. Thank you!


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Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University