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12 Core Competencies, Milestones, and Entrustable Professional Activities
109
tors in creating a shared mental model of a resident who has
reached a particular level of the competency. Each Core
Competency in family medicine is broken down in a similar
manner. [1].
Criticism ofCompetencies andMilestones
Core Competencies provide the curricular blueprint, and the
milestones provide guideposts for relevant development
points. The inevitable challenge then becomes translating
these broad, abstract concepts into granular components that
can be observed and assessed in meaningful ways. When
rst introduced, Core Competencies and Milestones faced
criticism for attempting to break down the complex work of
a physician’s practice into such simple parts. One set of
authors argued that “the measurable bits of performance that
follow from anatomizing clinical competence according to
discrete learning objectives do not and cannot add back
together to constitute the skill and ability of a competent
physician” [18]. In preparation to explore the practical application of competencies and milestones, it is worth exploring
this critique.
While impossible to delineate all aspects and qualications of a competent physician, there remains some level of
gestalt involved in the assessment process that permits a general agreement on what a “good physician” looks like, even
if it is not easily dened [15, 28]. Attempts to avoid a reductionist tendency toward endless lists of check boxes should
not, however, ignore the importance of having a shared mental model of physician competency. As health care continues
to evolve, residency programs must graduate physicians able
to provide safe, quality healthcare including the ability to
adapt to rapid practice evolutions, quality reforms, perform
in team-based care, and implement patient centeredness
[17]. Core Competencies and Milestones provide faculty,
residents, institutions, and society a reference of what skills,
knowledge, and attitudes they can expect from a Family
Medicine physician who has completed an accredited residency program. Core Competencies and Milestones encompass the desired outcomes used that should, in turn, inform
decisions regarding curriculum and assessment. Ultimately
there should be a balance of that gestalt of knowing what a
competent physician looks like with identication of areas
that can be explicitly taught and assessed with an emphasis
on providing highly granular feedback to learners. Instead of
a deconstructed, out of context collection of behaviors leading to long checklists removed from the actual work being
done, there should be a balance the lofty ideals enshrined in
the Core Competencies with the reality of assessing learners
in a real-world training environment. [20]. The goal becomes
to actively support a resident’s educational development by
anchoring curriculum and assessment to the Milestones
which promote mastery of the Core Competencies needed to
become a physician capable of quality independent practice
[1].
Entrustable Professional Activities
Programs looking to avoid dissected lists of an out of context
collection of behaviors must identify assessments grounded
in actual clinical training environments. Work-based assessments help bridge the lofty ideas enshrined in the Core
Competencies with the need to assess learners in the context
of the real world [20]. One particularly useful work-based
assessment tool is the Entrustable Professional Activity
(EPA). EPAs operationalize the Core Competencies and
Milestone using a safe engagement process of trainees within
a relevant clinical context and “transform abstract competencies into meaningful trainable and accessible pieces within
clinical contexts” [41].
EPAs at a most basic level are discrete, profession- specic
tasks that collectively make up the work physicians do and
dene the tasks of a physician [6, 33]. They require specic
knowledge, skills, and attitudes and when completed lead to
a demonstrable work outcome. Importantly, these tasks
require some type of oversight or supervision until a learner
has sufciently mastered the activity after an appropriate
amount of clinical experience and exposure to demonstrate
consistent knowledge and ability and assessed for formal
entrustment to perform the dened task with decreased or
indirect supervision. A task that does not require physician
training or could be performed without supervision would
not be appropriate for consideration as an EPA. EPAs set
minimum standards necessary to feel safe entrusting graduates in independent, unsupervised practice. In this way, EPAs
link Core Competencies to the actual clinical activities that
physicians perform [13].
With these criteria in mind, it should be noted that not
everything important or relevant in residency training can be
encapsulated into an EPA, nor should it be. EPAs by denition are physician specic tasks, so tasks not specically
linked to profession of being a physician or requiring specialized training to perform are not EPAs. Another key characteristic of an EPA is that it must be an activity requiring
supervision until competency has been attained [34]. Skills
around master adaptive learning or professionalism, for
example, while arguably important components of being a
physician require neither supervision to perform nor physician specic training. EPAs have an important role in training and assessment in outcome-based medical training and
for helping to demonstrate mastery of Core Competencies
and Milestones, but they should not be the only tool used.
EPAs should be independently executable, observable,
and measurable in both process and outcome [35]. By allow-
110
K. McCrory
ing the operationalization of competencies for assessment,
EPAs provide a transparent guide for learners and teachers
by translating the competency framework into the real world
[35]. EPAs must be meaningful and accurate descriptors of
the essential work required for clinical practice if they are
going to reframe learner assessment away from complicated
educational frameworks toward the utilization of more specic, actual physician work [33].
EPAs generally integrate more than one Core Competency
or Milestone [5]. They are the junction at which domains of
competency and the assessment within those domains meet.
As an outcome assessment tool, they help determine trainee
readiness to be safely entrusted with a specic task [37].
Although any given EPA may have multiple Core
Competencies or Milestones incorporated, not all competencies may be equally prominent. Connecting the most relevant
Core Competencies to a specic EPA can provide a guide for
curricular development, assessment tools, and learning
plans. Mapping EPAs derived by a residency program to the
Core competencies and Milestones allows educators to create a competency-EPA matrix that establishes evidence of
content validity for learning objectives [40].
Developing andImplementing Entrustable
Professional Activities
While the ACGME has provided a curricular framework
through the Core Competencies and Milestones, it has not
dened specic EPAs that could be used. Consideration of
potential EPAs within the vast scope of potential family
medicine professional activities can quickly become over-
whelming. One scoping review of EPAs in undergraduate
and graduate medical education programs, not limited to
family medicine, found that that the average number of EPAs
was 14, with a range of 3–79 [14]. Indeed, the list of what the
public can expect from a family doctor can grow quickly. An
early attempt to develop EPAs for family medicine identied
more than 70 items for consideration. Realistically, the literature has suggested that 20–30 to be a more attainable goal
[5]. The College of Family Physicians of Canada developed
34 core professional activities with associated sub-activities
that can provide guidance on relevant EPAs in Family
Medicine (The College of Family Physicians of Canada
[11]).
Programs may decide to create their own EPAs as well.
Important components of an EPA description including the
title, specications and limitations, consideration of potential risks in the event of failing to perform the EPA correctly,
and a list of the most relevant competency domains are outlined in Table 12.1 [34]. Ambiguity should be avoided.
Educational stakeholders should be able to read the description and understand exactly what a physician who had been
entrusted with the activity is able to do. Any specic contexts, such as limitations to specic patient populations or
clinical settings, in which the entrustment would not be valid
should also be identied. The EPA should have clear criteria
for when a resident can be considered to have sufciently
mastered the activity as well as how the decision on mastery
will be made and by whom. Box 12.2 shows an example of a
fully described EPA. As can be seen, some aspects of the
EPA may be program-specic and as such there is a benet
to programs creating their own or adapting those created by
external organizations.
Table 12.1 Components of entrustable professional activities [40]
Title Uses verb(s) to describe the activity to be performed
Description Components necessary to provide clarity to learners, teachers, and other stakeholders.
What is included in the scope of the activity?
What limitations, if any, apply?
Relevant competencies Which competency domains apply?
Which sub-competency domains apply?
Which specic milestones apply?
Required knowledge, skills, and
attitudes
Information to assess progress What data will be used to assess the learner’s ability to perform the EPA?
Estimate when unsupervised
practice can be expected
Basis for a formal entrustment
decision
What specic knowledge must the learner possess?
What skills must the learner demonstrate?
What attitudes must the learner have?
Are there existing standards/benchmarks available as a resource for comparison?
When will it be obtained?
Where will the information come from?
Keeping in in mind the need for exibility, approximately when in training would entrustment be
obtained?
When can formal entrustment be considered?
Who will determine this?
How will formal entrustment be communicated or documented?
12 Core Competencies, Milestones, and Entrustable Professional Activities
such activities that may be considered for such limited
Box 12.2 Example of an EPA
Title: Interpreting an EKG for common cardiac conditions in adult patients in ambulatory, inpatient, and
emergency settings.
Description: Learner accurately interprets EKGs
for the following common cardiac conditions: normal
sinus rhythm, sinus bradycardia, sinus tachycardia,
atrial brillation, atrial utter, premature atrial contractions, premature ventricular contractions, heart
block, left bundle branch block, right bundle branch
block, ST-segment elevation or depression, and T wave
inversion.
Relevant competencies: Medical knowledge and
patient care
Required knowledge, skills, and attitudes:
entrustment that do not involve formal EPAs [38]. When
considering broader structural entrustment, a smaller number of more formal EPAs may be more appropriate to determine entrustment [35]. Summative entrustment would be a
broader decision on decreased or complete removal of supervision indicating that no further oversight is necessary, and
the learner can always perform the specied activity independently [40]. Entrustability remains intrinsically linked to
the other components of EPAs. If the ultimate goal is to
ensure physicians complete training possessing the competencies necessary to provide safe and effective healthcare
within the communities and systems the work in, then it is
not sufcient to merely pass time in training. Faculty must
adequately assess and attest to the entrustability of their
trainees to perform as qualied physicians without the need
of ongoing supervision.
• Knowledge: Cardiac anatomy and physiology;
Normal and abnormal EKG characteristics.
• Skills: Identifying patterns/changes in EKGs wave-
forms suggestive of specic cardiac conditions;
Analyzing EKG within context of clinical history,
physical exam, and presentation; Prompt recogni-
tion of and initiation of appropriate intervention for
life-threatening EKGS.
sufcient experience, possesses adequate knowledge, and
demonstrates the necessary skills to be permitted to perform
the specied EPA without supervision. This is not a theoretical intention to trust, nor a decision of trustworthiness based
on having met an arbitrary time benchmark [35]. There must
be dened moments in which an entrustment decision occurs.
If an assessment of a trainee is to be considered valid, there
must be some collection of evidence that supports a nal rep-
Information to assess progress: Observation of
learner interpreting multiple EKGs in ambulatory,
emergency, and inpatient settings. Testing of learner on
EKGs demonstrating the required cardiac conditions
in simulated environment.
When is unsupervised practice expected: At the end
of intern year.
Basis for formal entrustment decisions: Need to
interpret a minimum of 60 EKGS before entrustment
can be considered including at least 5in each of the
required cardiac conditions. Entrustment will be deter-
resentation of a trainee’s competence [15]. While entrustment includes a component of assessment, it also includes a
level of risk as the decision is made not just with regards to
the performance assessment of the trainee. It also considers
the potential consequences for future patients, society, and
the healthcare system [40]. Entrustment is a prospective
judgment of the level of autonomy that a learner is ready for.
Unlike competencies, which exist on a continuum and can be
viewed from a development lens, entrustment is a discrete
decision. Either the learner is entrusted to perform the identi-
ed task, or they are not [37].
mined by assessing the EKGs interpretations in the
resident’s portfolio. Formal entrustment will be documented in the portfolio.
ticular professional activity we must frame the question in
terms of the risks: “How big is the risk of this student per-
forming seriously below the standard of care in a future
care, given his or her history and the newly collected infor-
mation” [15]. For example, an entrustment around perform-
ing a vaginal delivery would indicate that the trainee has the
Entrustment
background knowledge and mastered the clinical skills to
manage all aspects of the delivery, anticipate and address
Key to EPAs is the concept of entrustment [37]. Within the
context of residency training, faculty make many entrustment decisions. Ad hoc entrustment occurs when allowing a
resident to assess a patient independently and review with a
faculty member at a later time. In this case, an informal decision is made to entrust this learner at this specic time in this
specic activity within this specic context. There are many
potential complications, including getting help when
needed. When acknowledging the real risks of defaulting to
promotion based merely on time, both the negative and pos-
itive implications of entrustment encourage critical thinking
in terms of the entrustment decision [40]. Providing entrust-
ment to a resident who does not actually possess the neces-
sary components potentially places future patients at risk for
111
Entrustment is an intentional decision that a learner has
When considering an entrustment decision for any par-
112
complications and the resident at risk for future malpractice
litigation or disciplinary action. Appropriate entrustment
permits residents to be granted a higher level of autonomy in
their educational journey toward autonomous practice.
Specic questions can help to inform an entrustment decision by considering the learner’s knowledge and capability
to perform the activity in multiple contexts and conditions
(Box 12.3).
Box 12.3 Questions That Inform Entrustment Decisions
[40]
Does the learner know what to do?
Does the learner have adequate background
knowledge?
Is the learner aware of the risks and possible com-
plications of the activity?
What would the learner do in the case of unusual
presentations, rare ndings, emerging risks, or
complications?
By shifting the primary focus from time in clinical experi-
ences to intentional and specic assessment and entrustment,
we acknowledge it is not enough to say, for example, that
completing 3months of pediatric training makes you automatically competent to independently care for pediatric
patients, it is also clear that the experience, exposure, and
time spent in such training is vital to ultimately achieve such
competence [22, 26]. There should be a minimum experience or exposure necessary and through ongoing programmatic review and individual programs may determine that a
certain level of experience must be acquired before entrustment can be considered. However, entrustment decisions
should never be made solely on having had the experience
without also having a formal process for determining actual
competence [36].
Another key component in entrustment is the inclusion
of the learner in conversations around entrustment, particularly their own readiness for entrustability. Through the use
of EPAs, learners have a clearer understanding of the expectations they must meet as they strive for independent practice. This learner-centered nature of the process has a close
connection with the development of the skills of a master
adaptive learner. This process includes active participation
by the learner in reective practices. When considering
entrustment decisions, a powerful reection question for
learners is “what will you do when you don’t know what to
do?” [40]. Box 12.4 reviews other learner characteristics
that may come into play when considering entrustment
decisions.
K. McCrory
Box 12.4 Learner Characteristics Linked to Entrustment
[40]
Agency: a proactive attitude toward work, safety, and
personal development. We feel condent in entrusting
professional activities to our learners that have demonstrated that they consider it a professional responsibility to work safely and continue to work toward personal
improvement in their work.
Reliability: attribute of consistency, predictability,
and conscientious behavior. Reliability lends itself to
making decisions about how a learner will perform in
the future. Learners that have not yet developed reliability in a specied task are not yet ready for entrustment because you cannot easily predict that how they
will perform from instance to instance.
Integrity: characterized by both truthfulness as well
as patient-centeredness. Expertise employed to benet
patients and decisions are made with consideration to
best interests of the patients.
Capability: Ability to perform a specic task within
a specied context including understanding it’s place
in the overall clinical picture and having the ability to
communicate and work effectively in the system.
Humility: Having a self-awareness of their limits
and knowing when to ask for help. They seek feedback
and have an ability to learn.
Assessing andAddressing Curricular Gaps
Using Competencies and Milestones
While traditional curricular models have focused on lists of
learning objectives and check boxes of completed experiences ticked off in a succession of clinical rotations, the paradigm shift to an outcome or competency-based model puts
an emphasis on creating constructive alignments between
tailored learning experiences, competency-focused instruction, and programmatic assessment to help learners attain
competency in the expected outcomes. Teaching, learning,
and assessment will all need to be oriented toward these
learning outcomes [42]. As educational outcomes will be
considered in both accreditation and board eligibility, it
behooves programs to assess their educational programs.
Core Competencies and Milestones provide a framework for
this assessment.
An initial challenge in the development of a new process
includes acknowledgment of where a program may have previously fallen short. Learners may have been promoted
through residency because they completed a specied number of rotations without necessarily undergoing robust assessment. It may have been taken for granted that a learner who
12 Core Competencies, Milestones, and Entrustable Professional Activities
Table 12.2 Gap analysis tool
113
Milestone Where and how do we teach this?
completed all required rotations with acceptable, if sparse,
evaluations, must be competent. But consider the following
example using a sub-competency and related milestone from
the Family Medicine Milestones 2.0: System based practice
1: Patient safety and improvement which includes the following milestone: “Reports patient safety events through institutional reporting systems (simulated or actual)” [1].
There are many situations a resident may encounter an
opportunity to report safety events. However, if a program
has not intentionally identied the ways this can be demonstrated, assessed, and documented, a resident may fall
through the proverbial cracks. When the clinical competency
committee or other similar assessment group reviews the
resident, they meet with a conundrum on how to proceed
with a resident who has passed their rotations but lack
demonstrable evidence of valid assessments for all expected
outcomes [15]. If the resident never had the opportunity to
report such an event, what happens? Does the committee recommend promoting or graduating the resident as it was a
failure of the program and not the resident to ensure access
to the necessary educational components? Or is the resident’s promotion or graduation held until they have successfully demonstrated competency?
While this example identies one small component, without careful review of the educational program with an eye to
the desired outcomes, these small pieces can accumulate to
create much larger competency holes. Programs cannot
assume going through a specied of clinical rotations will
automatically address all necessary aspects of Core
Competencies or Milestones, rather having a curriculum and
assessment process that intentionally addresses these components can help to avoid competency holes.
Intentional curricular design begins with a thorough needs
assessment [16]. The ACGME has provided the expected
outcomes in terms of the Core Competencies and the developmental pace in terms of the Milestones. These become the
starting place to assess what is already in place, what can be
used with some adjustment, and what needs to be developed.
Focusing curricular decision making and delivery of instruction with an eye to diverse methods assures multiple opportunities for demonstration of all expected outcomes and
multiple chances for success. Outcomes becomes attainable
when the curriculum is intentionally designed around them
with multiple, low-stake opportunities accompanied by frequent formative feedback [16]. Although large in scope, pro-
Where do we observe and
provide feedback on this?
How and when do we
assess this?
grams can opt to tackle a few outcomes at a time or divide
them among different groups to ease the burden. Careful
consideration should be taken to determine relevant stakeholders. Not only should faculty and residents be part of the
process, but it may be advisable to also incorporate patients,
nurses, or support staff as well [13].
Clinical Competency Committees, which will be discussed further in the next section, hold a charge of identifying gaps in a program’s curricular or assessment program,
along with individual assessment for the purpose of individual success. Since the CCC benets from having eyes on the
performance data of each resident as well as the 10,000-foot
view of how residents are progressing through the program,
they have the access to the data needed to identify where the
program may fall short. For example, there may be a particular aspect of a milestone that residents are persistently not
meeting. Identifying that gap can allow a program to undergo
its own performance improvement process to identify where
the deciency is and develop a plan to remedy it. Box 12.5
shows questions that can be used by programs to do a curricular needs assessment. Table12.2 includes an example of
a gap analysis tool and Table12.3 provides selected methods
for addressing identied gaps.
Box 12.5 Questions for Conducting a Curricular Needs
Assessment
1. Have we identied the knowledge, skills, and attitudes necessary to be competent in this milestone?
2. Do we currently teach the components of this milestone/competency in the curriculum? If so, where,
how, and how often? Does anyone get missed? Do
all learners know this competency/milestone is
expected of them? How have we communicated
this expectation?
3. Do residents have multiple opportunities to practice
the skills relevant to this competency/milestone
under direct observation and receive formative
feedback on their performance?
4. Have we created intentional opportunities for learners to demonstrate this competency? If so, do they
occur more than once? If the opportunities are rare
(continued)
114
Box 12.5 (continued)
K. McCrory
Role oftheClinical Competency Committee
inaLearner Centered Assessment Process
or unpredictable, have we identied or created
additional methods for exposure (simulation, specialty clinic, etc.)?
5. Do we have specic criteria in place to assess a
learner in this competency? Are faculty aligned on
this criterion? Do the learners know what this criterion is? How is the communicated to residents?
How are assessments documented?
6. Are there relevant work based assessments, such as
EPAs, that can be included?
7. Are there other competencies or milestones that can
be linked?
The ACGME has embraced the importance of allowing
programs to focus on “exemplifying integrity to key concept
rather than specic practices” [42]. Programs can promote
local innovation while maintaining delity to the desired
outcomes. Using tailored learning experiences and electives,
competency-focused instruction, and programmatic assessment, programs can create curricular and assessment components for the required outcomes within the unique context of
their local program. The aim remains a commitment to providing educational tools for learner success that includes
meeting them where they are and tailoring the educational
program in a learner-centered way [13]. By designing a system that allows residents to acquire the required skills and
knowledge, they can more effectively demonstrate trustworthiness to provide care within the context of family medicine
[23].
Clinical competency committees (CCCs) were put in place
with the initial introduction of the milestones. The charge
to these committees remains monumental in nature, going
well beyond simply assessing resident progress through the
milestones. Among its many purposes, the CCC is expected
to develop shared mental models of resident performance,
identify and guide both underperforming and overperforming residents, identify gaps in the residency’s educational
program, provide opportunities for faculty development
and education, normalize constructive feedback, provide
transparency regarding performance expectations, and provide outcome data to enhance progress toward competencybased education. Stakeholders to the work of the CCC
includes the residency program, the program director, faculty members, program coordinators, residents & fellows,
institutions, and ACGME. [3]. The anchor for the CCC in
all of these endeavors is the Core Competencies and
Milestones.
Now with greater pushes on programs to implement a more
extensive integration of individual learning plans, there is also
a shift toward greater impetus for residents to actively participate in shaping their educational experience, including assessment [4]. Efforts continue toward tools to allow for immediate,
resident-led feedback as well as a new focus on creating robust
individual learning plans centering around core competency
assessments [4]. Milestones and Core Competencies continue
to be benchmarks by which residents will be compared and
through all of this transition, clinical competency committees
continue to be at the heart of this process and their initial
charges continue to be relevant and vital.
Table 12.3 Addressing identied gaps
Not explicitly teaching in the
curriculum
Include in didactic sessions such as
workshops, role-playing, grand
rounds, or morning reports.
Incorporate into teaching rounds.
Identify/create asynchronous
learning/teaching modules.
Empower residents to develop
individual learning plans based on
core competencies, milestones, and
core outcomes. Use self-audits to
review assessment data to inform the
individual learning plan.
Set up task force that includes
residents and community faculty to
identify where components t in
curriculum that already exists.
Not directly observing/providing
feedback
Set aside designated time within
learning events to provide feedback.
Incorporate simulation or
standardized patients to allow
observation and feedback.
Utilize video recording, peer
shadowing, two-way mirrors, or
other direct observation methods.
Use regular advisor meetings to
identify individual observation gaps
and set up plan to ll them.
Provide faculty development
specically geared at formative
feedback techniques with simulated
practice opportunities that includes
feedback.
Nor formal assessment or limited
assessment process in place
Provide faculty development
focused on assessment to an
agreed upon standards modeled
after the competencies,
milestones, and core outcomes.
Develop a learner portfolio as a
framework and process to
collect, analyze, and document
successful attainment of
competencies and core outcomes.
Use a designated group process
(such as clinical competency
committee) to determine critical
competence/entrustment
decisions
Set up multiple types of
assessments
EPAs/Entrustment Decisions
Short, practiced observations
Case-based discussions
Critical appraisal of a topic
Rotational reviews
Test results
Mini-Clinical evaluation
exercise (Mini-CLEX)
Objective Structured Clinical
Examination (OSCE)
Chart Audits
Quality/safety metrics
Patient/diagnosis logs
Patient experience surveys
Work-based assessments
during precepting
12 Core Competencies, Milestones, and Entrustable Professional Activities
115
Each residency program exists within a unique context
and each program’s CCC must operate within that context to
meet the broad expectations set forth by the ACGME.At the
heart of the learner centered assessment process must be a
culture of feedback anchored in a shared perception that
feedback is truly constructive and developmental in nature.
The CCC must engage learners in reective feedback conversations that are supported and facilitated by faculty advisors, mentors, and coaches. As part of its role in providing
opportunities for faculty development, the CCC should be
well versed in the shared standards of Core Competencies
and Milestones used to assess residents. There should be no
mystery as to the expected standard. The CCC provides the
transparency of how their program will identify performance
gaps, what residents should be doing to meet the expected
standards and using this information to enhance selfawareness and develop self-monitoring skills.
The CCC stands to collect data and provide a robust multifaceted program of assessment that include a deliberate
focus on improving competence and mastery of the Core
Competencies not simply identifying residents in trouble
[15, 16]. A successful program of assessment should center
around a mastery minimum benchmark of competency that
must be met prior to transitioning to the next phase of training or initiation to independent practice [23]. This assessment process should be seen as an undertaking that is done
with a resident and not something done to them. By working
together in co-production, residents become active agents in
their education [26]. This supports the development of selfassessment skills and an impetus to develop individual learning plans that will push them into the paradigm of master
adaptive learning, where the learner is not satised to sit on
their laurels but rather constantly pushes the limits of their
understanding and comfort to continuously improve [23, 24].
For residents who have not yet met expected benchmarks,
the need for additional work should not be viewed as punishment but rather a chance to identify elective options, additional
clinical experiences, and other resources to create additional
opportunities to meet the competency benchmark. When done
as part of the routine use of individual learning plans, the experience can be considered less punitive and more as part of the
expected variability of learners. By shifting the focus away
from a strict time metric, programs can shift away from extra
time needed as a remediation process and rather see it as a
normal time variability with the context of training. The individualized nature of learning requires a system that permits
some amount of exibility and adjustment to allow learners to
meet the benchmarks safely as well as the ability to creatively
use the workplace to fulll training needs [23, 41]. The
ACGME’s de-emphasis on specic rotational requirements
and focus on increased elective time provides resources for
residency programs to have exibility even within the connes
of a time-bound training program [2].
The CCC duties include empowering learners to seek out
opportunities for direct observation and guided selfassessments for the purpose of synthesizing data in an ongoing individual learning plan. Such empowerment requires a
culture of trust built into the learning environment. Learner’s
moving toward greater self-awareness can be done in concert
with CCC meetings, in preparation ahead of time for CCC
meetings, and within time frame following such meetings
where information and data has been provided. With faculty
guidance, residents should have the opportunity to review
their performance data, reect on how they think they are
doing as well as review factors that may be inuencing the
performance data. There should also be discussion on opportunities that present themselves based on available data for
further growth.
Faculty and CCC guidance remain an important component to this process recognizing that not knowing what you
don’t know, and other biases can lead learners to a awed selfassessment. Residents need to have data available to support
their self-assessments and when such data does not exist or is
contradictory, they need assistance in developing an ongoing
learning plan to adjust the course of action. This process can
include learners consistently reviewing their performance data
as a way to guide their own improvement plans in light of their
educational and career goals, identifying the necessary
resources for implementing those plans while understanding
potential barriers. There should also a be a dened timeframe
for reassessment as well as a metric to identify success. Those
metrics are most likely going to be the established Core
Competencies and Milestones but may also incorporate more
personal or program specic outcomes. Like any true quality
improvement project, residents will need to continuously
cycle back and see if they have achieved their goal through
intentional collection of relevant performance data. Thoughtful
reection on this data then helps course correction of the
learning plan when needed or, in the case of meeting the set
goal, helps to initiate the next step forward [29].
CCCs should also regularly participate in ongoing process evaluation to identify potential areas where they may be
making assessments without the most robust data, identify
improved assessment tools or techniques, and assessing
biases that may exist in their process. This evaluation process
should incorporate relevant stakeholders including CCC
members, non-CCC faculty, residents, and, perhaps, patients
and other support staff.
The Developmental Nature ofMilestones
andTheir Role inPromotion Decisions
Consideration for promotion or identifying a need for remediation relies on a standard ideal of competency as outlined
by the Milestones. This shared mental model allows pro-
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K. McCrory
grams to use that framework to assess progress [9]. Core
Competencies and Milestones provide the anchors that
inform faculty, residents, the CCC, and other stakeholders on
the expected developmental path residents should traverse in
their training. One particular challenge that may arise is that
the developmental aspect of the Milestones can be misconstrued as a grade by both residents and faculty, leaving a resident feeling disappointed when they are assessed at a level
one for most milestones at their rst clinical competency
meeting.
The progressive nature of Milestones should be understood as a developmental model of learning similar to
Dreyfus’s Model of Skill Acquisition [7, 24]. Dreyfus’s
model identies ve stages of learning: Novice, Advanced
beginner, Competent, Procient, and Expert. The predominant aspects of these stages lie in the use of analytic versus
non-analytic methods of clinical reasoning, emotional buy-in
and responsibility for decision making, comfort with ambiguity in cases and their management, and an ongoing commitment to self-reection and growth.
Novice learners practice from a set of rules. Lacking the
clinical experience needed to lter out irrelevant information, they provide complete histories and physicals with limited synthesis or unied or summary. They can effectively
note positive and negative components of reviews of systems
but are not able to use that information to home in on diagnosis or treatment. Unencumbered to any decision-making consequences, they may also be somewhat detached from the
process. These learners need guidance in identifying meaningful aspects of the history, physical, and ROS and eliminating extraneous information.
Advanced beginners continue to heavily use analytic
methods, but they have had some clinical experience that
allows them the ability to begin to focus on the history and
physical exams based presenting factors and pertinent positive or negative review of systems. They have started to
develop some pattern recognition and rudimentary illness
scripts, particularly for common conditions. Like novice
learners, they still lack signicant experience with the consequences of their decision making. These learners need
encouragement to formulate their own differential diagnoses
and treatment plans as they have greater clinical exposure in
an endeavor to build more robust illness scripts. Early
Milestones are developmentally analogous to Novice and
Advanced beginners. Residents are continuing to use the
rules they started to pick up in medical student as the moved
beyond the reporter stage to the interpreter stage.
Learners in Dreyfus’s Competent stage have enough
clinical experience to recognize common patterns with
ease, although they still rely more on analytics compared
to pattern recognition especially with atypical presentations or complex, uncommon conditions. In contrast to
learners in the Novice and Advanced beginner stages,
learners in the Competent stage have had sufcient continuity and repeat patients that they are aware of the consequences of their decision making. This leads to development
of a sense of responsibility for their decision making. In
more complex clinical situations, these learners may
become overwhelmed by the lack of enough rules to cover
all possible situations. Faced with the need to make decisions, they also grapple with the risks of those decisions
leading more emotional buy-in. Learners at this stage need
a careful balance of supervision and autonomy because
they must be empowered to make those hard clinical decisions and face both the good and bad outcomes. These
learners have less efciency in complicated cases as they
revert back to analytical methods due to a lack of sufcient
illness scripts available to them. The progression of
Milestones also shifts focus toward greater ownership of
patient care, team leadership, and management decisions
in more complicated cases.
Most residents will travel primarily through these the rst
three stages of Dreyfus as they progress through residency.
Some residents may begin to enter the Procient stage, but
Expert learners will likely not fully emerge until after initiation into independent practice where they develop a greater
tolerance for ambiguity and comfort in response to evolving
clinical situation [24]. In the Procient and Expert learner
stages, intuition predominates over clinical reasoning as they
more efciently use situational discriminators and pattern
recognition. Expert levels of experience also allow more
intuitive management and an openness to noticing the unexpected. They are thus able to see discriminating features that
do not t a recognizable pattern. In the highest Milestone
levels, glimpses of Procient and Expert can be identied
but most residents will graduate training before attaining
them.
Understanding where a learner falls in these stages can
help faculty identify where a learner is positioned on the
competency continuum. Attaining competency indicates a
resident has consistently demonstrated possession of all
required knowledge, skills, and attitudes in a certain context
at a dened stage of medical education. Key to dening competence and thus assessing for it lies heavily in understanding the context as that sets the expectations for promotion
and remediation. Competence requires dening with modiers to specify which abilities are in play as well as within
which stage of medical education or practice it refers to. For
example, an entering intern is incompetent to perform the
duties of a senior resident. It is not a slight on the intern, they
simply have not yet gone through the necessary education,
experiences, and exposure to have developed that competence. As we assess residents for the purpose of more summative or promotion purposes, programs must have a clearly
dened, transparent idea of the standard that residents will
be expected to meet.
12 Core Competencies, Milestones, and Entrustable Professional Activities
117
Considering competency or outcomes-based medical
education as the original impetus for the implementation of
the Core Competencies and the Milestones, programs should
have a shared mental model among faculty and residents of
what a learner within a particular context looks like. This
model should be based on relevant outcomes and not necessarily focused on time-based guides [16]. Instead of asking
what should a resident be able to do after 6months of training, reframe the assessment ideal to: what knowledge, skills,
and attitudes does a resident who will be under direct supervision for inpatient medicine need to demonstrate? Or what
knowledge, skills, and attitudes does a senior resident who
will be supervising a junior resident on labor and delivery
need to demonstrate. In terms of the Milestones, the question
may revolve around what does a resident who has achieved a
specic milestone level demonstrate in terms of knowledge,
skill, or affect?
By reframing assessments around the desired outcomes
and creating parameters to measure successful master of
such outcomes, benchmarks become available for promotion
as well as remediation. If the resident has not yet demonstrated all of the knowledge, skills, and attitudes to be
entrusted with the responsibilities they are being considered
for promotion to, then it is a disservice to the resident, their
fellow residents, their faculty, and ultimately their patients
and community to promote them. With a clear understanding
of the necessary components of competency in a specied
domain, remediation can be nely tuned to create individual
learning plans addressing those specic components. When
these criteria are transparent and available to all involved
stakeholder with frequent opportunities for direct observation and formative feedback, underperformance can be identied early and addressed, rather that uncovered unexpectedly
during summative promotion meetings.
Stepping Into theFuture ofOutcome-Based
Medical Education
The Core Competencies and Milestones started the journey
toward outcome-based medical education espoused by the
World Health Organization in the 1970s. After just over a
decade of development within family medicine residency
training, the ACGME and ABFM have delved further with
the two publications that note the ACGME and ABFM’s
commitment to a “signicant shift to competency-based
education” [26]. The ABFM indicated that the list of 15
Core Outcomes developed by the two organizations would
be used “to set standards for board eligibility,” setting the
expectation that commitment to a continuance of competency or outcome- based medical education goes beyond
residency training [26, 27]. The Core Outcomes will serve
to supplement existing Core Competencies and Milestones.
Core Outcomes, similar to EPAs, bring incorporate multiple Core Competencies. Differing from EPAs, however,
Core Outcomes are not limited to physician specic tasks
or only tasks that require supervision until mastered but
encompass equally important qualities of professionalism
and master adaptive learning. Over the course of residency
training, residents should be regularly assessed in their
developmental progress within the Core Outcomes with the
expectation that by the end of training they will have mastered all aspects of the Core Outcomes. Program directors
will need to attest to a resident’s mastery of each Core
Outcome as a criteria for board eligibility [27]. The same
principles described herein for developing intentional curriculum, creating learner centered assessment processes,
and rectifying program gaps using the Core Competencies
and Milestones can be applied to incorporation of the Core
Outcomes.
Pearls andPitfalls
Pearls
• Core Competencies and Milestones have been dened by
the ACGME [1]. These are the goalposts. Use them to
shape the curriculum and assessment of learners. Each
program’s context will inuence how learners reach the
goalposts, but the goalposts are constant.
• Work with residents and faculty who may have little experience with individual learning plans. Use the Core
Outcomes and Core Competencies to ensure that everyone meets the necessary metrics for graduation and board
eligibility. Engage residents to co-create the areas that
allow them to dive deep into areas they would like to
improve their condence, competence, or both.
• Engage learners early in the process to shape a culture
that fosters reective feedback conversations to meet the
benchmarks set by the Core Competencies and Milestones.
Remember that conversations are bidirectional. Engender
trust in the process through enabling multiple opportunities for direct observation, engaging ongoing faculty
development in providing meaningful feedback in learnercentered ways, supporting learners through the emotional
work of reective feedback and self- assessment, and role
model faculty both seeking out feedback and engaging in
their own processes of personal performance improvement [29].
• EPAs can be used in both large and small ways. Come to
a consensus as a faculty over where EPAs can best be
used within their specic program. Consider how to
implement entrustment decisions to allow for greater
learner autonomy in preparation for independent
practice.
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K. McCrory
• Clearly dene parameters for meeting metrics set by the
Core Competencies. The Milestones can help programs
guide assessments. Instead of looking at average training
performance, consider the question: “How big is the risk
of this learner performing seriously below the standard in
a future case given their history and the performance data
collected up to this point” [15]. Boxes 12.3 and 12.4 provide guidance on considerations in making entrustment
decisions. Do not promote residents based on solely on
time served.
Pitfalls
• Do not fall prey to endless checklists in an attempt to rigidly dene everything. Not all that is measurable is meaningful and not all that is meaningful is measurable. Resist
the urge to reduce assessments to merely milestone check
boxes. There can be a balance of the gestalt and more
objective dening of areas that can be explicitly taught
and assessed [17]. Although faculty frequently agree on
the competency of trainees, the process for reaching that
opinion can vary [28]. Additionally, even though there
may be some validity to an experienced educator’s overall
impression of a resident, the potential for bias must be
tempered with documentation of objective assessments
[30, 43].
• Strict rigidity to timelines counters the purpose and meaning of the milestones and outcomes. The focus should be
guiding a resident through the development of the necessary competency and less about specic timeframes.
Some level of exibility for individual learning and curricular context needs to be in place.
• Do not confuse entrustment with assessment. Although
assessment has a part in determining entrustment, they are
not interchangeable. Assessment looks to the past performance only whereas entrustment asks for the assessor to
make an informed decision about likely future performance within a particular context based on a number of
factors [37, 38].
• Learners must be at the center of implementing curriculum, assessment, and learning plans around milestones,
core outcomes, and EPAs. The purpose of competencybased medical education includes the development of
lifelong, master adaptive learners. Only through a learnercentered process with ongoing practice at guided selfassessment and self-reection can that be achieved [13].
• The implementation of milestones, core outcomes, and
EPAs is an ongoing iterative process. Do not fall into
complacency once processes are in place and fail to
undergo regular assessments to ensure that these processes are still meeting the needs of the program, the
learners, and the communities served. Programs and faculty should role model the practices of improvement and
excellence espoused in the milestones, core outcomes,
and EPAs.
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