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Stepping Stones to Milestones
EDITORIAL MUSINGS
Stepping Stones to Milestones John A. Weigelt, MD Editor-in-Chief The stack of papers on my desk discussing the Milestones projects keeps growing. Their content is similar. Our trainees are part of a learning continuum. Their advancement in the 6 competencies should be detectable as the individual progresses through the program. The faculty should be able to recognize the “milestones” in this development. At the end of the training period, we should have a surgeon who is competent in the 6 competency domains. All disciplines will have a list of milestones developed for 2013. Sounds logical and consistent with educational theory. Yet, I am worried that I will not be up to the task of navigating the steps that lead to these milestones! My first worry is whether I have the proper training to assess milestones among my trainees. I do not believe any of us, or very few, have the knowledge to do this type of assessment reliably. This type of assessment will take time and consistent exposure to a trainee. Time is a valued commodity for most faculty surgeons today as more relative value units (RVU) production is being championed. I doubt there will be RVUs assigned to these evaluation functions. Time is also a concern from the trainee’s perspective. Duty hour constraints limit the amount of faculty contact, especially among interns. I have heard many a faculty comment that recognizing a surgical intern is getting harder and harder, let alone providing a proper evaluation using our current system. I commonly mark “did not observe” or “inadequate contact” on evaluations more often now than I ever did in the past. A true assessment of each “milestone” will be no easy task. I predict it will force all of us in to reevaluate our roles, ability, and workflow. I worry about the use of checklists to accomplish these evaluations. Many milestone presentations have a checklist for various components. A consult was done. An operation performed. A disease presentation accomplished. While checklists are the current rage in medicine for everything from time-outs to discharge instructions, are they substantial enough to assess a milestone in one’s surgical education. The milestone project is at-
tempting to give us clearer accomplishments to assess how a resident is advancing in the training process. Better definitions of how we measure our trainees’ performance and improvement against the words for each milestone are certainly necessary. A key element of the milestone effort is “entrustable professional activities (EPA).”1 Entrustable professional activities are described as trust that is based on consistent satisfactory performance observed over time. EPA metrics will need to be discreet and measurable. This is really a great idea, but the devil is in the detail! As I read more about EPA, I am reminded of an Indian proverb. The saying is simple but profound. Do not judge a man until you have walked 2 moons in his moccasins. The implication is that it takes time to learn about an individual. Two moons indicate 2 months and whether that is an adequate or inadequate time to evaluate a surgical trainee for any assessment is certainly unknown. One can say that trust is usually not earned in a week or less. It is doubtful that I can judge operative skill after a few cases. It is unlikely that medical knowledge about a disease can be measured by 1 consult. Learning how to package a collective assessment of a trainee will be a challenge for all of us. I do believe in the Milestone Project. It is a great idea. It builds on the 6 competencies, making them measurable outcomes. It is the next step in the evolution of medical education. We will learn to adapt to the new system. It will stress our current system and force change. I am looking for the stress to be a positive influence as we retool our educational programs in surgery and medicine. I am confident that surgery programs will find the right steps to lead us to our goal of competency based training.
REFERENCE 1. Ten Cate O, Scheele F. Competency-based postgraduate
training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542-547.
Journal of Surgical Education • © 2012 Association of Program Directors in Surgery 1931-7204/$30.00 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.06.025
571
Stepping Stones to Milestones John A. Weigelt, MD Editor-in-Chief The stack of papers on my desk discussing the Milestones projects keeps growing. Their content is similar. Our trainees are part of a learning continuum. Their advancement in the 6 competencies should be detectable as the individual progresses through the program. The faculty should be able to recognize the “milestones” in this development. At the end of the training period, we should have a surgeon who is competent in the 6 competency domains. All disciplines will have a list of milestones developed for 2013. Sounds logical and consistent with educational theory. Yet, I am worried that I will not be up to the task of navigating the steps that lead to these milestones! My first worry is whether I have the proper training to assess milestones among my trainees. I do not believe any of us, or very few, have the knowledge to do this type of assessment reliably. This type of assessment will take time and consistent exposure to a trainee. Time is a valued commodity for most faculty surgeons today as more relative value units (RVU) production is being championed. I doubt there will be RVUs assigned to these evaluation functions. Time is also a concern from the trainee’s perspective. Duty hour constraints limit the amount of faculty contact, especially among interns. I have heard many a faculty comment that recognizing a surgical intern is getting harder and harder, let alone providing a proper evaluation using our current system. I commonly mark “did not observe” or “inadequate contact” on evaluations more often now than I ever did in the past. A true assessment of each “milestone” will be no easy task. I predict it will force all of us in to reevaluate our roles, ability, and workflow. I worry about the use of checklists to accomplish these evaluations. Many milestone presentations have a checklist for various components. A consult was done. An operation performed. A disease presentation accomplished. While checklists are the current rage in medicine for everything from time-outs to discharge instructions, are they substantial enough to assess a milestone in one’s surgical education. The milestone project is at-
tempting to give us clearer accomplishments to assess how a resident is advancing in the training process. Better definitions of how we measure our trainees’ performance and improvement against the words for each milestone are certainly necessary. A key element of the milestone effort is “entrustable professional activities (EPA).”1 Entrustable professional activities are described as trust that is based on consistent satisfactory performance observed over time. EPA metrics will need to be discreet and measurable. This is really a great idea, but the devil is in the detail! As I read more about EPA, I am reminded of an Indian proverb. The saying is simple but profound. Do not judge a man until you have walked 2 moons in his moccasins. The implication is that it takes time to learn about an individual. Two moons indicate 2 months and whether that is an adequate or inadequate time to evaluate a surgical trainee for any assessment is certainly unknown. One can say that trust is usually not earned in a week or less. It is doubtful that I can judge operative skill after a few cases. It is unlikely that medical knowledge about a disease can be measured by 1 consult. Learning how to package a collective assessment of a trainee will be a challenge for all of us. I do believe in the Milestone Project. It is a great idea. It builds on the 6 competencies, making them measurable outcomes. It is the next step in the evolution of medical education. We will learn to adapt to the new system. It will stress our current system and force change. I am looking for the stress to be a positive influence as we retool our educational programs in surgery and medicine. I am confident that surgery programs will find the right steps to lead us to our goal of competency based training.
REFERENCE 1. Ten Cate O, Scheele F. Competency-based postgraduate
training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542-547.
Journal of Surgical Education • © 2012 Association of Program Directors in Surgery 1931-7204/$30.00 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.06.025
571