Specificity Preferred
A needs assessment survey administered to internal medicine subspecialty program directors demonstrated that 85% preferred subspecialty-specific milestones as opposed to one set of milestones to be used for all divisions within internal medicine. This preference was also apparent among 78% of rheumatology fellowship program directors surveyed.5 Thus, ACGME, the American Board of Internal Medicine (ABIM) and the ACR joined together to create the Rheumatology Milestones 2.0 project, in addition to the harmonized milestones.
The goal of this work was to provide a practical, universal framework for the assessment and evaluation of rheumatology fellows and to create revised milestone language that allows for targeted, helpful feedback for trainees.
Key elements of the Rheumatology Milestones 2.0 project have been transparency of the process and involvement of individuals with diverse perspectives. Within the ACGME Rheumatology Milestones 2.0 Working Group were academic rheumatologists, a community practice rheumatologist, a rheumatology fellow in training and a member of the public who has a rheumatic disease and was able to provide a patient’s perspective. Several members of the working group were on the ACR Committee on Rheumatology Training and Workforce Issues, involved in the ACR Rheumatology Research Foundation Clinician Scholar Educator program, and on the ABIM Rheumatology Specialty Board.
The group was overseen by Laura Edgar, EdD, CAE, who serves as the ACGME vice president for milestones development and has extensive experience in medical education research and competency-based medical education. This diversity of positions and experiences allowed for robust discussion of how the milestones could best encompass all important elements of rheumatology training and patient care.
Beyond the composition of the working group, another great strength of the project has been the period of open public commentary that has allowed all stakeholders—clinicians, researchers, educators, patients and others—to express their thoughts. The notes collected from public commentary were invaluable and helped shape and modify the final version of Rheumatology Milestones 2.0.
The milestones include rheumatology-specific patient care and medical knowledge milestones. This greater specificity of milestones for rheumatology trainees is likely to make assessments more relevant and helpful to fellows and will truly highlight important strengths and areas for improvement.
The majority of the new milestones are versed in the language of domains rather than actions. This means that, as opposed to narrowly focusing on specific skills that may speak only to a fellow’s ability to perform an individual task, the new milestones reflect broader competencies that can translate to many different clinical settings and situations.
The 2.0 version of the Rheumatology Milestones eliminated the term critical deficiency, which was used to describe level 1 in the former internal medicine subspecialty reporting milestones, replacing it with the term novice for a level 1 learner and a subsequent reduction in negative connotations associated with the level. Thus, educators may feel more comfortable assessing a fellow at this level.
An entirely new feature of the revised rheumatology milestones is the creation of a Supplemental Guide, which includes examples of clinical environments and situations that depict each learner level for each milestone (https://www.acgme.org/Portals/0/PDFs/Milestones/RheumatologySupplementalGuide.pdf). Notes with respect to the development and intended use of each milestone shed light on the thinking of the Rheumatology Milestones 2.0 Working Group. References to tools and additional resources that may be helpful to rheumatology program directors, faculty and Clinical Competency Committees are also included.
Marcy Bolster, MD, associate professor of medicine at Harvard Medical School and director of the Rheumatology Fellowship Training Program in the Division of Rheumatology, Allergy, and Immunology at Massachusetts General Hospital, Boston, was a member of the Rheumatology Milestones 2.0 Working Group and nicely summarizes the positive outcomes of this work: “The Rheumatology Milestones 2.0 project offers a valuable, rheumatology-specific mechanism for assessing fellow performance, providing actionable features by which to depict a fellow’s progress in training,” she says. “The stages of learning and professional development are delineated in clear language with a succinct presentation, and there is a resource, the Supplemental Guide, to provide examples and context for each of the Milestone performance levels.”
