Milestones (ACGME)

The Milestones arrived in 2013 as the outcomes-based assessment framework of the ACGME Next Accreditation System, built on six competencies: medical knowledge, patient care, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice. Each specialty wrote its own set, which was deliberate, and which produced enough variation across specialties that comparing or validating assessment tools became difficult.

Milestones 2.0 addressed that variation for the competencies that apply to every physician regardless of specialty. The ACGME convened interdisciplinary work groups to harmonize the interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice domains, so those sub-competencies now read the same way across specialties. The harmonized ICS set has three sub-competencies: communication with patients and families (ICS-1), communication with teams and other health professionals (ICS-2), and communication within the health care system (ICS-3).

Each thread runs from Level 1 to Level 5, anchored so that Level 1 is basic identification and discussion of concepts, Level 4 describes the skills and behaviors expected for unsupervised practice, and Level 5 is aspirational rather than a graduation requirement. The ACGME treats milestone data as formative, meaning it exists to identify learning needs and drive curricular or individual change, not to function as a grade.

The people who wrote the harmonized ICS milestones were candid that assessment remains the hard part, because it is still an open question where, by whom, when, and with what instruments these sub-competencies get measured. A program can have the ICS milestones on the form and still have almost no observed conversation data to rate them against, which is the practical problem behind a competency committee's vague ICS scores.