The Psychiatry Milestone Project

This document presents Milestones designed for programs to use in semiannual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident progresses from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine aggregate Milestone performance data for each program's residents as 1 element in the Next Accreditation System to determine whether residents overall are progressing. Thus, aggregate resident performance will be an additional measure of a program's ability to educate its residents.

Program directors have the responsibility of ensuring that residents' progress on all 22 psychiatry subcompetencies (as identified in the top row of each Milestone table) is documented every 6 months through the Clinical Competency Committee (CCC) review process. The CCC's decisions should be guided by information gathered through formal and informal assessments of residents during the prior 6-month period. The ACGME does not expect formal, written evaluations of all Milestones (each numbered item within a subcompetency table) every 6 months. For example, formal evaluations, documented observed encounters in inpatient and outpatient settings, and multisource evaluation should focus on those subcompetencies and Milestones that are central to the resident's development during that time period.

Progress through the Milestones will vary from resident to resident, depending on a variety of factors, including prior experience, education, and capacity to learn. Residents learn and demonstrate some skills in episodic or concentrated time periods (eg, formal presentations, participation in quality improvement project, child/adolescent rotation scheduling, etc). Milestones relevant to these activities can be evaluated at those times. The ACGME does not expect that resident progress will be linear in all areas or that programs organize their curricula to correspond year by year to the Psychiatry Milestones. All Milestone threads (as indicated by the letter in each Milestone reference number, the “A” in PC1, 1.1/A) should be formally evaluated and discussed by the CCC on at least 2 occasions during a resident's educational program.

Thread names, preceded by their indicator letters, are listed in the top row of each Milestone table. Each thread describes a type of activity, behavior, skill, or knowledge, and typically consists of 2 to 4 Milestones at different levels. For example, the “B” thread for PC1, named “collateral information gathering and use,” consists of the set of progressively more advanced and comprehensive behaviors identified as 1.2/B, 2.3/B, 3.3/B, 4.2/B, 4.3/B, and 5.2/A,B. The thread identifies the unit of observation and evaluation. For PC1, thread “B,” faculty members would observe a resident's evaluation of a patient to see whether he or she demonstrates the collateral information gathering and use behaviors described in that Milestone. Threads do not always have Milestones at each level 1–5; some threads may consist of only 1 Milestone.

For each 6-month reporting period, review and reporting will involve selecting the level of Milestones that best describes a resident's current performance level. Milestones are arranged into numbered levels. These levels do not correspond with postgraduate year of education.

Selection of a level for a subcompetency implies that the resident substantially demonstrates the Milestones in that level, as well as those in lower levels (see figure). A general interpretation of levels for psychiatry is below:

• Has Not Achieved Level 1: The resident does not demonstrate the Milestones expected of an incoming resident.

• Level 1: The resident demonstrates Milestones expected of an incoming resident.

• Level 2: The resident is advancing and demonstrates additional Milestones, but is not yet performing at a midresidency level.

• Level 3: The resident continues to advance and demonstrate additional Milestones; the resident demonstrates the majority of Milestones targeted for residency in this subcompetency.

• Level 4: The resident has advanced so that he or she now substantially demonstrates the Milestones targeted for residency. This level is designed as the graduation target.^*

• Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating aspirational goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.

Faculty supervisors, especially those overseeing clinical care, will directly assess many Milestones. The CCC assessment is based on evaluations completed by these clinical supervisors along with other assessments, including performance on tests and evaluations from other sources. The process of Milestone assignment assumes that all residents are supervised in their clinical work, as outlined in the ACGME's supervision levels and requirements. For the purposes of evaluating a resident's progress in achieving Patient Care and Medical Knowledge Milestones, though, it is important that the evaluator(s) determine what the resident knows and can do, separate from the skills and knowledge of his or her supervisor.

Implicit in Milestone level evaluation of patient care and medical knowledge is the assumption that during the normal course of patient care activities and supervision, the evaluating faculty member and resident participate in a clinical discussion of the patient's care. During these reviews the resident should be prompted to present his or her clinical thinking and decisions regarding the patient. This may include evidence for a prioritized differential diagnosis; a diagnostic workup, or initiation; maintenance, or modification of the treatment plan, etc. In offering his or her independent ideas, the resident demonstrates his or her capacity for clinical reasoning and its application to patient care in real time.

As residents progress, their knowledge and skills should grow, allowing them to assume more responsibility and handle cases of greater complexity. They are afforded greater autonomy, within the bounds of the ACGME supervisory guidelines, in caring for patients. At levels 1 and 2 of the Milestones, a resident's knowledge and independent clinical reasoning will meet the needs of patients with lower acuity, complexity, and level of risk, whereas, at Level 4, residents are expected to independently demonstrate knowledge and reasoning skills in caring for patients of higher acuity, complexity, and risk. Thus, one would expect residents achieving Level 4 Milestones to be senior residents at an oversight level of supervision. In general, one would not expect beginning or junior residents to achieve Level 4 Milestones. At all levels, it is important that residents ask for, listen to, and process the advice they receive from supervisors, consult the literature, and incorporate this supervisory input and evidence into their thinking.

Please note that most Milestone sets include explanatory footnotes for selected concepts. These appear at the bottom of each Milestone table. The footnotes are essential tools in Milestone evaluation.

The figure presents an example set of Milestones for 1 subcompetency in the same format as the Milestone Report Form. For each reporting period, a resident's performance on the Milestones for each subcompetency will be indicated by:

• selecting the level of Milestones that best describes the resident's performance in relation to those Milestones, or

• selecting the “Has Not Achieved Level 1” response option.