In their summative description of the Accreditation Council for Graduate Medical Education Milestones, Ibrahim et al1 stated that the milestones represent core concepts of a specialty but are not high-stakes assessments to determine trainee progression.1 Since milestones represent the core concepts of a specialty, I feel that they should determine trainee progression, which can potentially shorten training via early graduation.
The length of training is changing for many physicians. Pediatric hospitalist medicine has emerged as a subspeciality,2 and there is a movement growing in favor of adding a year to family medicine residency.3 The job markets in pathology and radiology in recent years have made fellowships in these specialties necessary in many cities. With these transitions in mind, I ask: Why is it that every addition we see comes in full year increments? The answer is obvious. Graduate medical education has always had just as much to do with service requirements to institutions as it has with training.
If the milestones measure the extent to which a physician performs relative to a desired endpoint, doesn't it seem reasonable that a resident could complete the milestones and become Board eligible earlier than the prescribed training period? If not, is milestone completion really the measure of a trained physician? Of course, this may affect how residents are rated to keep them in service roles longer but raising the stakes with respect to the milestone system could enhance its validity. The milestone system can be no better than those who interpret the levels compared to other trainees they have worked with, but if programs can demonstrate an ability to train residents more quickly than planned, it could serve to mobilize physicians into practice more quickly.
Physicians are now scoring higher on standardized examinations than ever before,4 and it is plausible that they can learn medicine faster than prior generations. Our system has become streamlined by midlevel medical professionals who can enter practice in a fraction of the time it takes to train a physician. It may be time for us to let the milestones serve to get physicians into the workforce faster if they are ready, just as it is time to stop thinking about physician training as something that takes place in year-long increments. If the primary role of graduate medical education is to train physicians, then letting them practice as soon as they are trained seems reasonable.