ACGME Competencies and Milestones: What Does It Take to Be a Good Pathologist?

In 1998, the Accreditation Council for Graduate Medical Education (ACGME) advocated the Outcome Project, a competency-based paradigm for resident training. Previously, completion of a residency was based on a fixed number of years of training specific for each specialty. “Competency” to practice was based on the passage of a certifying board exam. Notable changes due to this initiative were the increased use of objective structured clinical exams (OSCE), increased resident engagement in quality improvement and evidence-based medicine projects, and the incorporation of additional didactics and approaches in GME curricula. Given all this, did the requirements for residency completion truly change?

In 2012, the ACGME introduced their standards for the evolution of the Outcome Project to the Next Accreditation System (NAS). Each specialty developed their own outcomes-based milestones within the 6 clinical competency domains. Residents are graded on a scale from 1-5 in each domain; level 4 represents the “graduation target.” Level 5 is the equivalent to the performance of a pathologist who has been in practice for several years.

The Milestones should be applied without regard to the trainee’s specific year. But would exceptional trainees then graduate earlier, and those who fall behind, later? Currently, the federal government funds residents based on a specific number of years for a given specialty. Can we apply the Milestones in a standardized manner for each AP/CP subspecialty? And what about a resident who excels in some rotations but doesn’t meet the Milestones in another? Anecdotally, based on a few pilot beta sites, each interpreted the Milestones and conducted their evaluation process, differently…so is there a best way to implement them? Or are there multiple, equally acceptable, ways?

In terms of the resident perspective, the 2013 ASCP Fellowship and Job Market Surveys, indicated that only 16% of residents felt that they were ready to sign out general pathology cases upon graduation and that 95% would seek fellowship positions. 59% of PGY-3 and PGY-4 felt that they needed fellowship training to feel confident in general pathology and 17% to address a perceived educational deficiency.

When I started residency, I was evaluated on a scale of 1-5 with 3 being “usually meets expectations,” (a permutation of the A-F scale we’ve all known since elementary school)in the 6 ACGME core competencies: 1) patient care, 2) medical knowledge, 3) practice-based learning and improvement, 4) interpersonal and communication skills, 5) professionalism, and 6) systems based practice. And for my next to final rotation of PGY-1,the same as my first, I was evaluated by my rotation director and performed a self-evaluation with the Milestones. We then met and discussed our respective evaluations. We pretty much agreed in scoring and with respect to those that we disagreed, I usually graded myself harsher.I’m not sure if one method of evaluation was better than the other – what I found most helpful in both processes were always the comments, not the numerical score.

So are the Milestones an improvement in terms of how we evaluate competency of residents for practice? Only time will tell.

You can find the Pathology Milestone Project, published in September 2012 at

Let me know how you feel about the Milestones and resident competency in our comments section.

-Betty Chung

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