New ACGME Milestones Implemented for Rheumatology Fellows in Training

Looking Ahead

Dr. Bolster

Although Rheumatology Milestones 2.0 holds great potential, it is not yet demonstrably clear these milestones will improve outcomes with respect to ease of use for faculty. It also remains to be seen if the milestones will yield improved quality of training for fellows or improved outcomes for patients.

The conceptual framework under­pinning the development and content of Rheumatology Milestones 2.0 seems promising, but will require ongoing surveys and focus groups to evaluate user friendliness. It may also be helpful to study whether the milestones can be used to discriminate between different fellows’ skill levels, strengths and weaknesses more accurately than the previous reporting milestones.

Of great importance in the future will be the ways in which training programs can best implement Rheumatology Milestones 2.0. Yaghmour and colleagues studied milestone implementation in 16 training programs across four medical specialties to better understand this process. These researchers found three stages of milestone implementation:

1. A resource-intensive early stage;
2. An increasingly efficient transition stage; and
3. A final stage for fine-tuning.

In this study, programs that created tailored assessment forms reflecting the expertise and clinical observation opportunities of raters reported improved completion and accuracy compared with programs that did not tailor forms in this way.

Moreover, programs that frequently checked in with faculty and Clinical Competency Committees reported increased faculty engagement.

The manner in which feedback was given to trainees also evolved on the basis of the milestone implementation stage, and the specifics of the feedback processes played a large role in shaping perceptions among residents. For example, it was not until the later stage of program implementation that feedback in these training programs was consistent, frequent, objective and filled with actionable items.

The researchers note that using the milestones to help trainees understand the context for feedback is an important way to help them understand their strengths and weaknesses and take ownership of their own professional development.⁶

Since the practice of medicine after residency and fellowship training relies so heavily on self-directed learning and improvement, a key goal of the milestones is to assist trainees in developing competencies that will serve them well throughout their careers. This is somewhat akin to the “teach a person to fish” rather than “give a person a fish” model, and many practicing rheumatologists recognize the importance of this distinction.

If rheumatology fellows can leave their training programs with the ability to recognize their areas of competence, as well as areas for improvement, they may be ready to accept ongoing growth and maturation over the course of a career. Keeping up to date on the medical literature, being cognizant of the various forms of bias that can sometimes hinder clinical reasoning, being an effective communicator with patients and colleagues, and understanding the ethical principles that should guide patient care are but a few of the complex issues that rheumatologists face even decades into practice. These new milestones seek to allow trainees to graduate their training programs ready to face these challenges head-on from their first day of independent practice.

The new milestones represent a potentially transformative step toward the future of medical training and education. Dr. Bolster expresses enthusiasm about the future and notes, “I look forward to implementation of the Rheumatology Milestones 2.0 by rheumatology fellowship training programs in July 2021 and to obtaining longitudinal feedback, because further modifications may be important to align with the needs and goals of our training programs.”